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)
UNIFORM REPORTING SYSTEM PREVENTION SERVICES
OUTREACH FORM
Page 2 of 2
* BOLD FIELDS MUST BE COMPLETED
* AGENCY NAME: Harlem United Community AIDS Center, Inc. Population At Risk? Target Group:
No 01 Staff
* CDC RISK FOCUS:
Area Risk:
Yes
01 MSM & IDU
Medium
03 Volunteers
02 Clients 03 IDU
02 MSM
High
04 Peers
04 HETEROSEXUAL CONTACT
Specific Target Audiences / Locations
Low
~
05 General Population
06 Students
05 MOTHER WITH OR AT RISK FOR HIV INFECTION
1 206
2
06 GENERAL POPULATION
3
Please Enter 3-Digit Code From List Below For 1, 2, and 3 Audiences / Locations On The Above Lines 100 Health Providers 101 Designated AIDS Center Hospital(s) 102 Other Hospital(s) 103 Emergency Medical 104 Home Health Care 105 Long Term Care Facility / Hospice 106 Developmental Disabilities 107 Psychiatric / Mental Health 108 Women’s Health (FP / WIC / PCAP) 109 HIV Anonymous Site(s) 110 Community Health Center(s) / D & TC 111 Substance Use Services
200 Community 201 Educational Setting(s) (Schools) 202 Parent Organization(s) 203 Religious Organization(s) 204 Govt / Business / Industry 205 CBO / Human Service Provider 206 General Community 207 Sex Workers 208 Soup Kitchens 300 Adolescents 301 Adolescent Services Agency 302 Youth Groups
400 Law Enforcement / Corrections 401 Correctional Facility / Jail / Detention 402 Facility Parole 403 Field Parole 404 Rape Unit 405 Legal Services 500 Housing 501 Shelters 502 Hotels 503 Supportive Housing 504 Other 600 Internal
Other Targeted Population(s) ~ Focus On Special Population(s) Targeted Approximate # Of Participants
Population 01
Gay Men
Approximate # Of Participants
Population 11
Methods Of Delivery
IDU
01A Bisexual Women
12 Same Sex Contact
01B Lesbian
13 Sex Contact With IDU
01C Bisexual Men
14 Transgender – Identify As Male
02
Adolescents
15 Transgender - Identify As Female
03
Migrants
20 White / Non-Hispanic
04
Immigrants
30 Black / African American
40
05
Homeless
40 Hispanic
18
50 Asian / Pacific Islander
07 Substance Users
60 Native American
08 Prisoners / Parolees
61 Sex Worker
09 Minorities
68
01 Theater 02 Resource Table 03 Door To Door 04 One-On-One 05 Structured Socialization 06 Lecture 07 Informal Group Setting 08 Mass Mailing 09 Workshops 10 Drop In Center 11 Agency Meeting 12 Network / Group Meeting 13 Radio 14 Television 15 Media Campaign - Press 16 Media Campaign – Billboard / Static Display 17 Hotline / Phone Bank 18 Walk / March / Parade 19 Other
68
06 Women
99 Other
10
10 Unprotected Heterosexual Contact
Service(s) Provided
Materials Provided
01 Street Education
13 Referral For HIV-Related Medical Care
100 Condoms
02 Counseling
14 Referral For Gyn
200 Bleach Kits
03 Food
15 Referral For OB
04 Clothing
16 Referral For Family Planning
05 Health Care
17 Referral For Substance Use Related TX
205 Safer Sex Kits
Please Circle Appropriate Responses
Quantity 120
Materials Provided 400 Promotional Materials 410 T-Shirts
120
210 Health Hygiene Kits
420 Buttons 430 Key Chains
68
68
06 Referrals
18 Referral For Alcohol Use Related TX
300 Literature
07 Other
19 Referral For Social Services
310 English Literature
450 Hats
08 Transportation
20 Referral For Case Management
320 Spanish Literature
460 Female Condoms
09 Token / Bus Fare
21 Referral For Mental Health Services
330 Bilingual Literature
470 Dental Dams
10 Cab Fare
22 Referral For Counseling
11 Demonstration of Latex Barriers
23 Referral For Pediatric Primary Medical Care
12 Referral For Primary Medical Care
24 Referral Pediatric HIV-Related Medical Care
340 Other Literature
Quantity
68
440 Other
20
480 Posters / Signs
Remarks:The female population have been asking for Dental Dams. Is it possible we can order some?
New York State Department of Health, AIDS Institute, Systems Development
* MS WORD *
August 2003 (URS v4.1c)