NNAAPC Clearinghouse Worksheet by parpar

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									   National Native HIV/AIDS Awareness Day Campaign
    PRODUCTS/INCENTIVES REQUEST FORM & EVENT QUESTIONAIRE

INSTRUCTIONS: To order products from the National Native American AIDS Prevention Center, please complete this form
and sent via email to information@nnaapc.org or fax to 720-382-2248, attention NNAAPC Clearinghouse or call in a
request to 720-382-2244 between 8:00 a.m. to 5:00 p.m., Mountain Time.
                                          RECIPIENT CONTACT INFORMATION
Request Date:                                               Date Needed:
Name:                                                       Job Title:
Tribal Affiliation(s):                                      Tribe(s) Served:
Agency Name:
Program Name:
Address:
City:                                                            State/Zip:
Phone No:                                                   Fax No:
Email Address:                                     Would you like to be added to our list-serv?          Yes      No
                                         PRODUCTS ORDER LIST                                              QUANTITY
                                                           Poster
National Native HIV/AIDS Awareness Day                     Save the Date Card (Version 1)
Products:                                                  Save the Date Card (Version 2)
                                                           Button
                                         INCENTIVES ORDER LIST                                            QUANTITY
                                                           Condom Keychain
National Native HIV/AIDS Awareness Day                     Drawstring Backpack (Red)
Incentives:                                                Drawstring Backpack (Black)
                                                           Drawstring Backpack (Blue)
NNHAAD Toolkit: NNHAAD Toolkit includes an Activities Sheet, Fact Sheet, PowerPoint Presentation, and
more. Download the toolkit at http://www.nnaapc.org/news/nnhaadtoolkit/nnhaadotk01.htm
The Native Red Ribbon HIV/AIDS Pendleton Blanket is now available in exchange for a financial donation.
There are only a limited number of blankets available. For more information about the blanket and donation
options, visit NNAAPC’s website at http://www.nnaapc.org/news/blanket.htm
                           NATIONAL NATIVE HIV/AIDS AWARENESS DAY EVENT PLANNED
Event Name:
Event Date:                                               Event Time:
Event Location(s):
Street Address
City/State/Zip
Brief Description of Event Activities:

Sponsors, Co-Sponsors, and Collaborating Partners:

Are you having multiple events? Yes , No If so, would you please provide all of the event names, dates,
times, locations, descriptions, sponsors, co-sponsors, and collaborating partners in the space provided at the
bottom of this sheet.

Who is your target population?

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What type of HIV prevention services does your program provide?



Does your program work in Rural      , Reservation   , or Urban     settings?

Is your HIV prevention program funded? Yes      , No

If yes, where does your funding source come from? (check the appropriate box(s) below)
Tribal Health , City/County Health Dept , State Health Dept. , CDC , HRSA , OMH , Other
                  MULTIPLE NATIONAL NATIVE HIV/AIDS AWARENESS DAY EVENTS INFORMATION
Event Name:
Event Date:                                           Event Time:
Event Location:
Street Address:
City/State/Zip:
Brief Description of Event Activities:

Sponsors, Co-Sponsors, and Collaborating Partners:

Event Name:
Event Date:                                               Event Time:
Event Location:
Street Address:
City/State/Zip:
Brief Description of Event Activities:

Sponsors, Co-Sponsors, and Collaborating Partners:


                                            Good Luck With Your Event(s)!




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