Consumer Survey

Please take a few minutes to fill out the following survey. It is for demographic use only to assist us in determining the needs of people living with HIV/AIDS and their families. This survey is completely anonymous. Your name is NOT required at any point.

Please list your:

County Choose one only Allegheny Armstrong Beaver Butler Cambria Fayette Green Indiana Somerset Washington Westmoreland

City

Gender Choose one only Female Male Transgender - female to male Transgender - male to female

Ethnicity Choose one only Alaskan Native African-American Asian/Pacific Islander Causasian Latino/a Native American Other

Marital/Partner Status Choose one only Single - never married Married Living with partner Comon law marriage Seperated Divorced Widowed

Stage of HIV Infection Choose one only Newly diagnosed (under 6 moths) HIV+ - asymptomatic HIV+ - symptomatic AIDS HIV negative Don't know

Comments:

 

 

 

Do you have concerns in the following areas:	Yes	No	N/A
Denied services
Transportation
Child care or other specialized services for mothers, families, and children
Food
Housing
Appropriate medical care
Access to HIV-informed physicians, hospitals, and other care givers
Mental health services
Appropriate drug and alcohol support and rehabilitation programs
Social support

N/A = Not Applicable

 

AIDS Related Services

 

 Where do you go for medical care? (check one only please) Choose one AGH Positive Health Clinic Butler Children's Hospital Forbes Regional Greensburg / UPMC Mercy PACT / UPMC West Penn none

Other source of care not listed:

Are you aware of any AIDS Service Organizations, other than medical providers or caseworkers, in your area? yes no

Which AIDS service organizations have you used? (check all that apply)

PATF - Pittsburgh AIDS Task Force	PACT - Pittsburgh AIDS Center for Treatment
SWC - Shepherd Wellness Community	Senior Care Management
Persad	Pitt Men's Study
PETU - Pittsburgh Evaluation and Treatment Unit	HOPWA - Housing Opportunities for People with AIDS
none

Other organizations not listed:

What is your source of AIDS information? (check all that apply)

AIDS service organizations	Books
Case manager / social worker	Friends
Internet	Magazines / newsletters
Doctor / Pharmacist	Support groups
none

Do you feel that AIDS funding resources are used appropriately in your area?

yes no

 

Case Management Information

 

Please answer the following questions:

Do you know what a case manager does? yes no

Do you have a case manager? yes no

If not, why?

If you do have a case manager, does she/he keep in regular contact with you? yes no

How regular? Check only one daily weekly biweekly monthly not applicable

Does your case manager respond to phone calls with in a reasonable amount of time (e.g. 48 hours)? yes no

If your casemanager is not available in an emergency, are you directed to someone else who can help you? yes no

Are you generally satisfied with the services provided by your case manager? yes no

 Other suggestions:

 

Thank you for taking the time to complete this survey. Your answers will help us determine what recommendations to make to the Southwestern Pennsylvania AIDS Planning Coalition, the distributing body for AIDS funds in the eleven county southwestern region. If you would like to become a part of the Consumer Advisory Board and help to make a difference, please go to our on-line registration form or call 412-242-2441 for further information. All inquiries and applications are kept in strict confidence.