Register

Please fill out this form or print and mail or fax any of the following forms:

General Information

Organization Name
Contact Name
Middle Initial
Last Name
Title
Address Line 1
Address Line 2
City

State
Zip
Telephone
Fax
Email
Are you a member of any Prevention Organization? Community Planning Group
STD Prevention Partners
Prevention Planning Group
Health Dept.
Other (please describe):
Select the category for your organization Directly Funded by the CDC
Funded by local Health Department
Funded by State Health Department
Private & Community fundging sources
Other (please describe):
Referral Source - How did you hear about our services? CDC Project Officer
Local Health Department
Web Site
State Health Department
Employer
Manos Unidas Website
Colleague or Co-worker
Manos Unidas Brochure
Other (please describe):

Demographics

Primary Work Setting AIDS Treatment Center
Alcohol/Drug Treatment
CBO Community Agency
Hospital
Child Welfare Services - Foster Care
Correctional Facility
Educational Institution
Mental Health Services
Family Planning
Health Center
Health Department
Other (please describe)
Primary Occupation Administrator
Community Educator - Outreach Worker
Counselor/Therapist
HIV Test Counselor
Social Worker/ Case Manager
Other (please describe)

Agency Services

Target Populations (check all that apply) LGBT
Homeless
Latinos/as
Puerto Ricans
Dominicans
Central Americans
South Americans
Mexicans
Sex Industry Workers
Incarcerated Persons
Youth
Women
Persons Living with HIV/AIDS
Health Care Providers
Students
Substance Users
Other (please describe)
HIV/STD Prevention Service providedd by your agency (check all that apply) Individual Counseling
Peer Education
Group Counseling/Support Services
Outreach
Rapid Testing
Orasure
Western Blot
Elisa
HIV/AIDS Treatment
STD Testing/Treatment
STD/HIV Education Programs
Case Management
Partner Referral Services
Substance Use
Reproductive Health Services
Other(please describe)

DEBI(s) interested in implementing (check all that apply)

Safety Counts
Healthy Relationships
SISTA
Street Smart
RAPP
POL
Many Men Many Voices
Voices
Community PROMISE
MPowerment
Other (please describe)

Have your organization implemented any of the DEBI’s?
Yes
No
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Fact Sheets and Prevention Information
Manos Unidas E-List Alert
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LCOA E-List
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