HealthHIV Technical Assistance Request Form 2018

Contact Information

Thank you for your interest in receiving technical assistance (TA) from HealthHIV. Please submit this brief online TA request form. If you have any questions or concerns related to submitting a TA request, please contact prevention@healthhiv.org or 202-232-6749. Once your information is submitted, a HealthHIV staff member will contact you within five (5) business days to conduct an initial assessment of your training or TA needs.

Question Title

* 1. Contact Information:

First Name:

Last Name:

Organization:

Job Title:

Work Address:

City:

State:

Zip:

Work Phone:

Work Email:

Organization Website:

Question Title

* 2. Which of the following describes your organization? (Please select all that apply)

AIDS Service Organization

Community Health Center

Community-Based Organization

Faith-Based Organization

Federally Qualified Health Center or Look-Alike

Health Department

HIV Planning Group

Municipality/Government

Primary Health Care Setting

Other (please specify)

Question Title

* 3. Please specify your position within your organization? (Please select only one)

AIDS/HIV or STD Director

HIV Prevention Program Manager

Ryan White Administrator

Executive Director or CEO

Chief Financial Officer

Program Director/Manager

Other (please specify)