First Name:                    Middle Initial:

Last Name:    

Organization:       

Dept:             

Title:                        

                   Check if Home Address

 Address:     

 City:                  State:        Zip Code:

 Phone:               Fax:    

 Email:                   

County You Work In: Please select one Albany Allegany Bronx Broome Cattaraugus Cayuga Chautauqua Chemung Chenango Clinton Columbia Cortland Delaware Dutchess Erie Essex Franklin Fulton Genesee Greene Hamilton Herkimer Jefferson Kings Lewis Livingston Madison Monroe Montgomery Nassau New York Niagara Oneida Onondaga Ontario Orange Orleans Oswego Otsego Putnam Queens Rensselaer Richmond Rockland Saint Lawrence Saratoga Schenectady Schoharie Schuyler Seneca Steuben Suffolk Sullivan Tioga Tompkins Ulster Warren Washington Wayne Westchester Wyoming Yates

1. Check off the trainings you want to attend.
    All trainings will be held in Syracuse, NY

Building Bridges to Cultural Competency: July 21, 2008

HIV and STDs: July 29, 2008

Developing Skills for Advanced Outreach (4 Days): August 7–8 and August 21–22, 2008

The ABCs of Hepatitis and HIV:  August 12, 2008

Overview of HIV Infection and AIDS: September 12, 2008

Improving Health Outcomes  for HIV Positive Individuals Transitioning from Correctional Settings to the Community: September 15, 2008

Basic Information about Domestic Violence: September 25, 2008

Practicing the NYS Domestic Violence Screening Protocol: September 26, 2008

Reducing the Risk & Harm of HIV: October 1–3, 2008

HIV/AIDS Treatment Update: October 10, 2008

Addressing Prevention in HIV Case Management: November 18, 2008

Building Bridges to Cultural Competency: December 4, 2008

HIV/AIDS Confidentiality Law: December 12, 2008

2. Number of Years in Current Occupation:
    Please Select One 0-1 2-4 5-7 8 or more

3. Primary Work Setting:
    Please Select One AIDS Treatment Center CBO/Community Agency Child Welfare Services/Foster Care Correctional Facility/Jail Educational Institution EMS/Police/Fire Family Planning/PCAP Health Center Health Department Hospital Mental Health Services Non-Institutional Nursing Services Nursing Home/Adult Care Center Physician's Office/Lab Other

4. Primary Occupation:
    Please Select One Administrator COBRA CFW COBRA CM/CMT Community Educator/Outreach Worker Counselor/Therapist Criminal Justice/Law Enforcement Domestic Violence Provider Emergency Personnel HIV Test Counselor MR/MH Worker Nurse NursePractioner/Physician's Assistant Physician Social Worker/Case Manager Teacher/Trainer/Student Other

5. Educational Level:
    Please Select One Less than 12 years High School/GED College 1 College 2 College 3 College 4 Graduate Degree

6. Ethnicity:
    Please Select One Hispanic or Latino Not Hispanic or Latino

7. Race:
    Please Select One American Indian or Alaskan Native Asian Black or African American Native Hawaiian or Pacific Islander White More than one race Unknown/Unreported                                      

Thank You

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