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Condom Distribution Application
CONDOM DISTRIBUTION APPLICATION
Date
*
Organization Information
Hours of Operation
*
Days of Operation
*
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Organization Name
*
Type of Organization
*
Government Agency
Health Care/Social Services
Business
Faith-Based Organization
School
Other Community Participation
Contact Name
*
Alternate Contact
Phone Number
*
Alternate Phone Number
Email Address
*
Alternate Email Address
Address
*
City
*
State
*
Florida
Zip Code
*
Does your organization agree to accept and fulfill walk-in requests from members of the community for condoms?
*
Yes
No
Can the Florida Department of Health list your organization or site as a location for free condoms?
*
Yes
No
Does your organization agree to the following?
Your organization will provide condoms in an on-site location that is visible and accessible to clients
*
Yes
No
Your organization will provide condoms in an on-site location that does not expose condoms to direct sunlight, flourescent light, moisture, and/or extreme high or low temperatures. The acceptable range is between 59 - 86 degrees Fahrenheit. *No bathrooms please, as the moisture can compromise condom quality
*
Yes
No
In each of the categories below, please check ALL that apply for your organization
Gender
*
Male
Female
Transgender
Other
Other Gender
*
Ethnicity
*
Hispanic
Non-Hispanic
Haitian
Other
Other Ethnicity
*
Race
*
White
African American/Black
Asian/Pacific Islander
American Indian/Alaska Native
Multiracial
Other
Other Race
*
Target Population
*
Heterosexual
Women
Youth (13-24 yrs old)
MSM
Transgender
Injection drug users
Other
Other Target Population(s)
*
Age Ranges
*
0-12 Yrs Old
13-19 Yrs Old
20-29 Yrs Old
30-39 Yrs Old
40-49 Yrs Old
50-59 Yrs Old
60+ Yrs Old
Does your organization serve those who are HIV positive?
*
Yes
No
Does your agency organization serve those who are High-Risk HIV Negative?
*
Yes
No
Quantity of male condoms requested per quarter
*
1 case = 1,000 male condoms
Quantity of female condoms requested per quarter
*
1 bag = 100 female condoms
How did you hear about us?
*
Event
Google search
Healthcare provider
Friend
Other
Other how you heard about us
*
Have you seen the "Getting 2 Zero" campaign?
*
Yes
No
Where did you see it?
*
Agree to Terms
*
YES - I agree that the information furnished in this application is being submitted for purposes of providing HIV prevention services to clients in Miami-Dade County, and that these supplies are to be distributed, free of charge, to the general public as requested and based on availability.
Director/Manager's Signature
*
This acts as your Electronic Signature
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