Division of Social Work
Northwest Indiana HIV/AIDS Needs Assessment Survey
download survey

Help is needed in collecting information as soon as possible.  If you know of someone that has HIV/AIDS and who lives in Lake, Porter, and LaPorte Counties in Indiana, please make them aware that their help is needed.  Either direct them to this site, or please download and print a copy of the survey to give to them.

The Division of Social Work at Indiana University Northwest has received a grant from the Indiana Minority Health Coalition to conduct a needs assessment for the Ryan White HIV Title III Planning Grant.  The needs assessment will target people who live with HIV (PLWH) in Northwest Indiana.  The purpose of this study is to learn about the HIV/AIDS prevention and service needs of communities in Lake, Porter, and LaPorte Counties in Indiana.

This needs assessment is a vital component to the overall planning process for the Lake County Ryan White HIV Title III Advisory Council.  A proposal for early intervention services will be submitted to the HIV/AIDS Bureau of the Health Resources and Services Administration.

The results from participation will be held in the strictest confidence by all individuals involved in this needs assessment.  Any reports or publications resulting from this needs assessment will not identify the participant by name.

We would greatly appreciate you participation in completing this survey.   The possible benefits of participitating in this needs assessment may help identify those factors that interfere with prevention of acquiring the HIV virus or access to necessary services.

Please download the Word 6.0 file which contains the survey.

English Word 6.0 Survey   Spanish Word 6.0 Survey

When completing this form in Microsoft Word, it will be hard to circle or underline answers...you may indicate your answers from multiple choice selection by leaving the correct answer, deleting the ones that do not apply to you.  Should you wish to print the survey and make changes by hand, please leave survey as is, and circle or check items as requested.  Once you complete the survey you may save it, and:

We must receive this survey by August 25, 2000 to meet our deadline.

Thank you for your participation

Denise Travis, PhD, MSW, ACSW, CCSW
Office Phone: 219-981-5618  or  FAX:  219-981-4264

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Comments:  Dr. Denise Travis