1. Which do you have?
HIV AIDS I don't know
2. How do you describe yourself from the following?
Female Male Transgender Other (Please specify)
3. How do you describe yourself from the following?
Bisexual Heterosexual/Straight Homosexual/Gay/Lesbian Other (Please specify)
4. Which of the following age groups best describes you?
0-24 25-44 45-64 65 and over
5. Which of the following ethnicities best describes you?
American Indian/Alaska Native Asian American/Pacific Islander Black/African American Hispanic/Latino(a) Multiracial White/Caucasian Other (Please specify)
6. Please list which northern Nevada or northern California County do you live in?
What is your current zip code?
7. How long have you lived in northern Nevada?
Less than one month One month to two years Over two years
8. What lanquage(s) do you speak? (Check all that apply)
English Spanish Other (Please Specify)
9. How comfortable are you in receiving HIV/AIDS services in English?
Very comfortable Somewhat comfortable Somewhat uncomfortable Not comfortable
10. Which best describes you? (Check all that apply)
I work full time I work part time (Less than 40hrs week) I am on disability I am a student I am retired I am a volunteer Other (Please specify)
1. Do you have access to social services through HOPES?
Yes No
2. I receive social service assistance with (Please check all that apply)
Housing (HOPWA) Social Security Disability Food Pantry referral Assistance with utilities Substance Abuse counseling Mental Health counseling Social support services (support groups, art classes, cooking classes, etc.)
3. Do you have a social service case manager?
4. How often do you see your case manager?
Every 0-3 mos Every 3-6 mos Every 6 mos to a year More than a year I have never seen a case manager
5. Are you satisfied with your case manager's assistance?
Very satisfied Satisfied Dissatisfied Very dissatisfied
6. How often do you feel comfortable sharing your thoughts and feelings with your case manager?
All of the time Most of the time Some of the time Rarely Never / Does not apply
7. How would you rate your case manager's knowledge in social service resources and programs available to you?
Excellent Very good Average Fair Poor Not sure
8. How often does your case manager go over your service plan and update it to fit your current needs and progress?
All of the time Most of the time Some of the time Rarely Never Does not apply
9. How often do you wish you had more involvement in making decisions about your service plan/goals or social service interventions?
10. How would you rate Northern Nevada HOPES' Case Management services OVERALL?
Excellent Good Fair Poor Unknown
11. How would you rate Northern Nevada HOPES housing programs?
12. How would you rate Northern Nevada HOPES' Food Pantry?
13. Are you a Veteran? (Served in the United States Military)
If you answered yes, which of the following services do you receive: (Check all that apply)
HOPES Social Services Service Connected Benefits Non Service Connected Benefits Other Veteran Administrative Benefits
14. Do you receive Substance Abuse Treatment?
If you answered yes, which services do you receive?
Inpatient referral Outpatient referral Support Groups (AA/NA) Other: (Please specify)
15. How would you rate HOPES' Substance abuse program referrals?
1. How would you rate convenience and flexibility of clinical appointments?
2. How convenient is it to have a phlebotomist on site at HOPES' Clinic?
Very convenient Somewhat convenient Not very convenient Not convenient at all Unknown
3. How would you rate Northern Nevada HOPES' Nutritional Services?
4. How would you rate Northern Nevada HOPES' Clinic Services OVERALL?
5. How would you rate the convenience and availability of Women's Health Services?
6. How would you rate the convenience and availability of assistance with being adherent to your medication?
7. How would you rate the convenience and availability of assistance with managing medication side effects?
8. How would you rate the convenience and availability of help paying for health insurance or COBRA?
9. How would you rate the convenience and availability of access to Dental Services?
10. How would you rate the convenience and availability of access to Vision Services?
1. How would you rate the convenience and availability of prescription services at HOPES' Pharmacy?
2. How satisfied are you with ADAP (AIDS Drug Assistance Program) Services?
Very satisfied Satisfied Fairly satisfied Not satisfied Unknown
3. How satisfied are you with the medicine co-pay assistance program?
4. How would you rate Northern Nevada HOPES' Pharmacy Services OVERALL?
1. How would you rate Northern Nevada HOPES' personnel OVERALL?
Administration:
Social Services:
Clinic:
Pharmacy:
2. How would you rate Northern Nevada HOPES OVERALL in providing services to the HIV+ Community ?
1. What changes would you like to see at Northern Nevada HOPES?
2. What would encourage your involvement in the HIV+ community?
3. What services do you feel will be needed to meet the ever-changing needs of persons living with HIV? (i.e. financial planning, job re-entry, life skills, family planning)
4. Where would you like to see HOPES in the next 5 to 10 years?
5. Do you have any other comments regarding Northern Nevada HOPES' services in the community?
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