1. I am providing feedback about:
www.hivla.org (Web site)
HIV L.A. print directory

2. I am (Please check one):
A Service Provider
Not a Service Provider

3. How did you hear about HIV L.A.?
Saw an advertisement
Received a copy from a service provider
Internet
Received a copy in the mail
Other (specify)

4. Please select the sections of this directory that you have consulted (select all that apply):
Case Management
Drug Treatment
Fact Sheets
Food and Nutrition
HIV/STD Testing
Housing
Hotlines and Crisis Lines
Legal Services
Medical Resources
Mental Health
Prevention
Public Benefits
Transportation
Women/Youth Services
Work-related Resources
Youth Assistance
Other (specify)

5. Did the use of the HIV LA Directory increase your knowledge of available HIV/AIDS services?
Yes
No

6. Did the use of this directory increase your ability to successfully access HIV/AIDS services and resources in L.A. County?
Yes
No

7. Did you read any of the Fact Sheets on the HIVLA website?
Yes
No      (If no, skip to # 10)

8. Did the Fact Sheets on the HIVLA website increase your knowledge about the service(s) you inquired about?
Yes
No

9. Were the Fact Sheets easy to find?
Yes
No

10. Did you access services as a result of using this directory?
Yes
No

11. Do you plan to use this directory again?
Yes
No

12. Is the information in this directory easy to read and understand?
Yes
No

13. Please give an overall rating of this directory:
Excellent
Good
Neutral
Fair
Poor

14. Please provide any additional comments you may have, including suggestions for improving this directory, or positive or negative reactions: Type your response here

Please provide some demographic information about yourself. This information is anonymous and will help us better tailor our services.

15. Gender (choose only one response):
Female
Male
Transgender (M to F)
Transgender (F to M)

16. What is your age?:
18 or younger
19 - 29
30 - 49
50+

17. What is your ZIP code?:

18. Which best describes your racial/ethnic background? (Please choose only one.)
White/Caucasian
American Indian/Alaska Native
Black/African American
Hispanic/Latino
Asian/Native Hawaiian/Other Pacific Islander
Other (specify) 

19. Are you HIV-positive?
Yes
No
Don't know 
Decline to answer

Thank you for providing feedback about the HIVLA Directory. In appreciation of you time, you are invited to participate in a raffle for a $100 gift card. If you are interested, please provide a phone number or email where we can contact you at. This information will only be used for the purpose of awarding the winning prize.

Telephone Number:
Email Address:

In order to ensure privacy we are not asking for your name. Your answers to this evaluation form will not be tied to your name or identity. Instead, please create a Unique ID by providing the following information:

First Initial of First Name:
First Initial of Last Name:
Month of Birth as a 2 digit number
    (i.e. Jan= 01, Dec=12):
Year of Birth as a 2 digit number
    (1979=79):

Click on the Submit button below to send in your response.