Outreach Profile


To Coordinator:
Please fill out the following Outreach Profile based on your knowledge of those attending this outreach along with completed Panel Request Form. The more we know about you and those attending the better we can tailor the program to maximize the success of greater awareness of HIV & AIDS for you.


NAME OF ORGANIZATION:

BOROUGH:
AGE RANGE OF VISITORS:

ANY SPECIAL NEEDS :



GENDER COMPOSITION OF GROUP:

(total # or %)


  Female
  Male


ETHNIC COMPOSTION:

(total # or %

  African American
  Caribbean
  Mexican
  Other Latino/a
  Dominican/Puerto Rican

  White (non-Hispanic)


  South American
  Pacific/Asian
  Don't know
  Other
(specify)

RELIGION:
(total # or %)

  Catholic
  Buddhist
  Episcopal
  Other Christian (Protestant, Baptist, etc.)

  Hindu
  Muslim
  Jewish
  No affiliation





TO THE BEST OF YOUR KNOWLEDGE:


Do your attendees know someone LIVING with HIV or AIDS:
Yes
No
Unknown

If yes, check all that apply (total # or %)

  Mother
    Father
  Aunt
  Uncle
  Brother
  Sister
  Grandparent
  Godparent
  Friend
  Stepmother or father
  Other person
  Themselves


Do your attendees know someone who has DIED of AIDS:
Yes
No
Unknown

If yes, check all that apply (total # or %)

  Mother
    Father
  Aunt
  Uncle
  Brother
  Sister
  Grandparent
  Godparent
  Friend
  Stepmother or father
  Other person


HAVE YOUR POTENTIAL ATTENDEES:
• Seen the AIDS memorial quilt before?
Yes
No
Unknown
• If so, have any made a panel
Yes
No
Unknown

• Volunteered for any AIDS organization or health facility (i.e. hospital, clinic)?
Yes
No
Unknown



WHAT HIV/AIDS EDUCATION HAVE YOUR ATTENDEES RECEIVED?


HOW WILL OUR PRESENTATION HELP YOUR CURICULUM/GOALS?






Please remember to fill out the Panel Request Form as well!