If you have experienced discrimination while trying to access healthcare because you identify as gay, lesbian, bisexual, or trans*, or because you are gender non-conforming or intersex, we would like to learn a little bit about the experience you have had. Don’t worry, it shouldn’t take long! We can compile the details of your experience to inform research and ultimately advocacy in order to prevent this kind of discrimination from happening again or to other people. Your responses will be compiled by the SANAC LGBTI Sector, as well as researchers working at UCT and the Triangle Project. Name We need your mobile number so that we can combine this data with similar responses we’ve received via mobile phone. Unless you’d rather we not contact you, we might also phone you to get more details about your experience. Enter your phone number here if you don’t mind us calling: Do you identify as any of the following? L G B T I Other (specify below) Because you’re LGBTI, you were: Insulted/humiliated Judged Asked unnecessary questions Refused care Sexually harassed Not given information you wanted Who treated you in that way? (Pick most important one.) Nurse Doctor Counsellor Admin staff Security staff Cleaning staff Other patients Where did this happen? Province: Name of clinic/hospital: When did this happen? Month: Year: If you would like to elaborate on any part of your experience, please feel free to tell us what happened below: Thank you for sharing your experience. If you didn’t want us to contact you, then this is the last you’ll hear from us. If you agreed to let us contact you, then maybe we’ll talk soon! If you need further assistance or have any questions, please contact, Triangle Project, OUT LGBT Well-being, or the Durban Lesbian and Gay Centre. Or, check out our database for other LGBTI-friendly resources in your area.