Name *

Sex * MaleFemale

Phone Number *

E-Mail *

Race * AfricanWhiteColouredIndianOther

Sexual Orientation * Same GenderOpposite GenderBoth

Highest Qualification * Less Than MatricMatricDiplomaDegreePost-Graduate Degree

Monthly Income * Less Than R4 999R5 000 - R9 000R10 000 - R19 000R20 000 - R29 000R30 000 - R39 000R40 000 - R49 000R50 000 - R59 000R60 000 - R69 000R70 000 - R79 000R80 000+

Province * Eastern CapeFree StateGautengKwazulu NatalLimpopoMpumalangaNorth WestNorthern Cape

City / Town *

Words that best describe HIV/AIDS to you? * Normal LifeManageable VirusSicknessThe End

When was your last HIV/AIDS test? * 1-4 weeks1-3 months3-6 months1 year2 years3 years3 years+

Did you do a follow up test? * YesNo

If you are/were HIV/AIDS positive, would you disclose your status? * YesNo

Reason? *

Do you know your HIV/AIDS status? * YesNo

If HIV/AIDS positive, are you on treatment? * YesNo

If on treatment, do you understand the benefits of treatment? * YesNo

Reason *

Words that best describe HIV/AIDS in the community you live in * Normal LifeManageable VirusSicknessThe End

In your perception, is your community HIV/AIDS friendly? * YesNo

Reason *

Has someone disclosed their HIV/AIDS status to you? * YesNo

Relationship Status * SingleDatingMarried

How long have you been together? *

Do you know your partners HIV/AIDS status? * YesNo

Are you sexually active? * YesNo

Do you use protection i.e. condoms? * YesNo

Would you date someone who’s HIV/AIDS positive? * YesNo

Reason *

Do you think current campaigns on HIV/AIDS are effective? * YesNo

Reason *