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Counseling, Testing & Linkage (CTL)
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Calendar
Know The Facts
HIV/AIDS
Sexually Transmitted Diseases (STDs)
PrEP/nPEP
Living With HIV
Statistics
Resources
Get Tested
Get Treated
Condoms
FAQs
Become A Partner
Condom Ordering Form
Condom Locations
Get Free Condoms
Female FC2 Condom
Resources
HIV Prevention
Request Our Services
HIV/AIDS 101 Video
Community Services
National HIV/AIDS Awareness Days
Community Initiatives
Providers Corner
Submit An Event
Counseling, Testing & Linkage (CTL)
Trainings
Calendar
Request Our Services
Community Request Form
Disclaimer: Please allow a minimum of 4 weeks advanced notice for all requests.
Date of Request:
Date of Event:
*
Beginning time - End time of event:
*
Name of Organization:
*
Address:
Phone number:
*
Email:
*
Contact Person:
*
Requested Services:
STD/HIV Education
STD/HIV Testing
Health Education
PLWH Education
LGBTQ Education
Transgender Education
Health Fair (Educational Table)
Session for Men Only
Session for Women Only
Event Details
Event Description:
*
Type of Event:
*
In-person
Virtual
College/School
Platforms Used:
*
Blackboard
GoToMeeting
Microsoft Teams
Google Meet
Zoom
Canva
Skype
Other
Number of people expected:
Please Describe Target Audience (by Gender, Race/Ethnicity, Age Group):
Will there be other service providers at the event ?:
*
Yes
No
Language:
English
Creole
Spanish
Materials needed:
Condoms
Brochures
Other
Restrictions (e.g. no condoms, no sexual content images):
Will you provide AV Equipment ?:
Yes
No
Site Accommodations (for Testing and Health Fair only)
Room near a Bathroom:
Yes
No
Private area for Confidential Screening/Testing:
Yes
No
Tents/Tables/Chairs will be provided:
Yes
No
Space for Mobile Unit(s) (each Mobile Unit requires at least 5 parking spaces):
Yes
No
How many Mobile Units requested:
1
2
3
4
5
How did you hear about us?:
*
Event
Google search
Healthcare provider
Friend
Other
Other, please specify source:
*
Comments:
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