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1. Where are you located?
Other, please mention

2. How old are you?

3. What is your education?

4. What is your monthly salary or income?

5. You are...

6. In your life, which gender you have had sex with?
(can answer more than 1)
Male and Female

7. When was the last time you tested for HIV?

8. Are you infected with HIV?

9. In the past 6 months, how many people have you had sex with?

10. Did you use condom in your last insertive or receptive anal sexual intercourse?

11. In the past 6 months, do you use condom with your partner?

12. In the past 6 months, have you use the following recreational drugs such as poppers, amphetamine or ecstasy?

13. If yes, How often do you use? (Your information will be kept anonymous and confidential)

14. When was your last time you were at risk for HIV infection and have not received HIV testing yet?

15. In the last time you were at risk. Could you specify the county, city, district where it happened? (If there is no risk you can say there is no risk).

16. When do you plan to come for HIV testing in next time?