Thank you for taking the time to fill out our survey. All information will be submitted anonymously and results will be kept confidential. WAGE will use this survey to determine topics of discussion for programming on Reproductive Health.

Gender

Are you sexually active?
Yes
No

What contraceptives, if any, do you use?

Would you be interested in learning more about different types of contraceptives?
Yes
No

Are you familiar with Emergency Contraception?

Yes
No

If yes, have you or your partner ever had to use Emergency Contraception?

Yes
No

Are you familiar with the Family Planning Waiver Program?

Yes
No

Send information on... (multiple options)
Emergency Contraceptives
The Pill
Condomsg Else
Different Types of Contraceptives
Family Planning Waiver *
Pelvic Exams
STDs
Safe Sex
Breast Exams
Abortion
Men's Health

*(if you qualify, you can receive all of your reproductive health care for free, including
annual exams andbirth control through the Family Planning Waiver Program)

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