Feedback

Name:
Address:
Organization:
Phone Number:
Fax Number:
E-mail Address:

Personal information (optional):

Urban Suburban Rural

Age:

Race:
Caucasian African American Latino/Latina Asian-Pacific Islander American Indian Multi-Racial or Other

Serostatus:
HIV Negative HIV-positive AIDS Never Been Tested/Don't know Decline to Answer

I am:
A person with HIV/AIDS A health-care professional A social worker
An interested citizen An AIDS or treatment activist

Check the one which most describes you:
I test HIV-negative or have never been tested or decline to answer
I am a gay male
I am an infected woman
I am a gay male and former or current injection drug user
I am an infected former or current injection drug user
I am a bisexual person
I am a transgendered person
I am a lesbian
I am a hemophiliac

I take:
AIDS antivirals (AZT, ddI, ddC, D4T, 3TC)
protease Inhibitors
prophylaxis for PCP (Bactrim/Septra, aerosolized pentamidine)
prophylaxis for other opportunistic infections
use alternative therapies
use vitamines and/or nutritional supplements

My CD4 count is:

I know my viral load which is:

I have a case manager: Yes No

I have health insurance: Yes No

I use the Critical Path AIDS Project Web Page for:

CDC AIDS Daily Summary
Primarily Frequently Seldom Never

Clinical Trials Listings and Information
Primarily Frequently Seldom Never

AIDS Treatment Newsletters
Primarily Frequently Seldom Never

AIDS Newsletters Search Engine
PrimarilyFrequently Seldom Never

sci.med.aids Search Engine
Primarily Frequently Seldom Never

Calendar of Philadelphia Events
Primarily Frequently Seldom Never

AIDS Meetings Listings (national/international)
Primarily Frequently Seldom Never

AIDS journal articles and documents and databases
Primarily Frequently Seldom Never

Resource Directories (Philadelphia)
Primarily Frequently SeldomNever

Resource Directories (National)
Primarily Frequently Seldom Never

Resource Directories (International)
Primarily Frequently Seldom Never

Materials in Asian Pacific Islander Languages
Primarily Frequently Seldom Never

Case Management Databases
Primarily Frequently Seldom Never

Background documents/fact sheets on Drugs and Therapies
Primarily Frequently Seldom Never

Legal Information
Primarily Frequently Seldom Never

Housing Information
Primarily Frequently Seldom Never

Support Group Information
Primarily Frequently Seldom Never

Prevention Information
Primarily Frequently Seldom Never

Research Information
Primarily Frequently Seldom Never

Treatment Information
Primarily Frequently Seldom Never

Services Information
Primarily Frequently Seldom Never

Non-AIDS Information (using links or InfoSeek)
Primarily Frequently Seldom Never

I mainly use my Critpath Email for the following:

I would like to see the following added to your Web page:

My main criticism of your Web page is the following:

Additional Remarks:

I would like to make a tax-deductable contribution/memorial donation to your organization to support your free World Wide Web and Internet gateway and other electronic services for the PWA community.

Please send check or money order to: Jenny Pierce, Philadelphia FIGHT, 1233 Locust Street, Philadelphia, PA 19107. Please make checks out "Philadelphia FIGHT" and note that the donation is for the Critical Path Project.

Thank you for participating in this Feedback.