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General Information

Organization Name
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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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Manos Unidas is a CBA program funded by CDC under announcement 04019