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.

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NAME OF ORGANIZATION:

BOROUGH:

AGE RANGE OF VISITORS:

ANY SPECIAL NEEDS :

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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

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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

• 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

HOW WILL OUR PRESENTATION HELP YOUR CURICULUM/GOALS?

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