UNIFORM REPORTING SYSTEM PREVENTION SERVICES
OUTREACH FORM
Page 1 of 2
* BOLD FIELDS MUST BE COMPLETED
* AGENCY NAME: Harlem United Community AIDS Center, Inc. / Village Well * SESSION / ACTIVITY * CATEGORY
* LOCATION
(Please Circle Appropriate Response)
* TYPE (CDC LOCATION)
* TYPE
001 OUTREACH (Anonymous) (Client Level Data is not gathered)
1A INDIVIDUAL LEVEL HEALTH EDUCATION / RISK REDUCTION 1B GROUP LEVEL HEALTH EDUCATION / RISK REDUCTION
01 CBO
06 DRUG TREATMENT FACILITY
02 COMMUNITY SETTING
07 CORRECTION / DETENTION
03 CLINIC / HEALTH CARE FACILITY
08 SCHOOL / EDUCATIONAL 99 OTHER
04 HIV C / T SITE 05 STD CLINIC
Organization/Outreach Venue: The
1C PROGRAM PROMOTION (to other providers)
Address:
1D CLIENT RECRUITMENT
City:
LAB
1428 Fulton St
Brooklyn
State:
NY
* ZIP:
1E GENERAL INFORMATION AND CONDOM DISTRIBUTION * PROGRAM:
County:
WBA
Contact: * ACTUAL DATE:
6/ 5/ 6 * TIME START:
10 : 00 PM
Scheduled Date:
/
Additional Zip Codes Covered: Session Presented By:
/
01 Staff
02 Peers
* TIME END:
Session Staffed By: XF, PL
3 : 00 AM
Guest Lecturer:
03 Volunteers
04 Guest Lecturer
* DEMOGRAPHICS OF PARTICIPANTS * TOTAL PARTICIPANTS:
DEMOGRAPHICS KNOWN:
68
DEMOGRAPHICS UNKNOWN:
* RACE / ETHNICITY (NH) = NON-HISPANIC HISPANIC:
* GENDER:
MALE: FEMALE:
60
18
(NH) WHITE: (NH) BLACK OR AFRICAN AMERICAN:
8
TRANSGENDER: FEMALE ID AS MALE:
(NH) ASIAN:
TRANSGENDER: MALE ID AS FEMALE:
(NH) NATIVE HAWAIIAN / PACIFIC ISLANDER:
40
(NH) AMERICAN INDIAN OR ALASKAN NATIVE: MORE THAN ONE RACE / ETHNICITY:
* AGE GROUPS: CHILDREN (UNDER 13):
10
OTHER:
ADOLESCENTS (13 TO 19):
18
20 TO 29:
48
30 TO 49:
2
UNKNOWN / UNREPORTED:
50 AND OVER:
New York State Department of Health, AIDS Institute, Systems Development
* MS WORD *
August 2003 (URS v4.1c)