First Name:                    Middle Initial:

Last Name:    

Organization:       

Dept:             

Title:                        

Select One:
Work Address         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 Outside of New York State

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

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

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3. The newsletters have been useful and informative: Choose One Strongly Agree Agree Disagree Strongly Disagree

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Thank you!
Your feedback will help us to make next year’s newsletters better meet your needs.
The winner will be contacted by June 29th and announced in the next newsletter.