National African American Hepatitis C Action Day 2016 Survey

1.Our organization agrees to participate in National African American Hepatitis C Action Day 2016 (NAAHCAD) to bring attention to the community about the impact of HCV among African Americans.(Required.)

Yes, our organization will participate in NAAHCAD 2016.

2.Organization Name(Required.)

3.Organization Information(Required.)

Contact Name:

City/Town:

State:

ZIP:

Country:

Email Address:

Phone Number:

5.Annual Budget(Required.)

6.National African American Hep C Action Day(Required.)

Yes

No

Did your organization participate in NAAHCAD in 2014?

Yes

No

Did your organization participate in NAAHCAD in 2015?

Yes

No

7.Please tell us about your 2015 NAAHCAD event(s). (Check all that apply.)(Required.)

Outreach & Testing - Testing and linkage to care

HCV Health Literacy - Workshop to educate the community

Social Marketing Campaign - Facebook, Twitter, Instagram, other

Town Hall/Policy Intervention - Target policy-makers and legislators

Other (please specify)

8.Do you need capacity building assistance?(Required.)

Yes

No

11.Risk (Check all that apply)

High Risk Heterosexual

IDU

PLWH

12.T-shirt size (Total Qty 2)

Qty

Medium

Large

X-Large

2X-Large

3X-Large

13.Please provide details about your event.

We will be in contact soon, in the meantime, If you have any questions, please e-mail Melissa Baker at info@nblca.org. We look forward to working with you.

The National Black Leadership Commission on AIDS, Inc., (NBLCA) is a 501c3, not for profit organization with a mission to educate, mobilize, and empower Black leaders to meet the challenge of fighting HIV/AIDS and other health disparities in their local communities. Founded in 1987, and headquartered in New York City, NBLCA is the largest nonprofit organization of its kind in the United States.