Exposure to infected blood in health care settings
	A mosquito bite
	Sharing a needle or works to inject drugs
	Sharing food with someone infected with HCV
	Being born to a mother with HCV
	Sharing personal care items, such as razors or toothbrushes
	Getting a piercing or tattoo using unsterile equipment
	Receiving a blood transfusion or organ transplant before 1992
	Having sexual contact with someone infected with HCV

	Yes
	No
	Not sure

	My health care provider suggested I get tested
	I asked to be tested
	I was notified by a blood/tissue donation organization or a public health official saying that I might be infected
	Other:

	I do not believe I am at risk for HCV infection
	The test was never offered to me
	I don't want to be tested
	Other:

	Yes
	No (skip to question 13)

	Less than 1 year ago
	1 to 5 years ago
	6 to 10 years ago
	More than 10 years ago

	Yes
	No
	Not sure

	Yes
	No
	Not sure

	Yes
	No

	I haven’t discussed treatment with my health care provider
	My health care provider told me I don’t need to be treated
	I cannot be treated because of another medical condition
	I am worried about the side effects of treatment
	I cannot afford the cost of treatment
	I am waiting for new medications to become available
	Other:

	Primary care physician (NOT a specialist)
	Infectious disease specialist
	Gastroenterologist
	Hepatologist
	Other:

	My health care provider
	Friends and family
	The Internet
	Magazines or books
	Hepatitis newsletters
	Hepatitis support groups
	A national or local organization

	Male
	Female
	Transgender
	Other

	Straight
	Gay/Lesbian
	Bisexual
	Other

	American Indian or Alaska Native
	Arab or Middle Eastern
	Asian
	Black or African American
	Hispanic or Latino
	Native Hawaiian or other Pacific Islander
	White
	Other: (please specify)