Organizational Capacity Building Referral Form

I. Contact Information

Agency/Program Name:

Contact Name: *

City: *

State: *

Zip: *

Phone:

E-mail: *

II. Agency Description

If other, please describe:

2. What HIV/AIDS programs/services does your agency provide? (Check all that apply): *

If other, please describe:

3. Does your agency/organization receive Ryan White Funding?: *

Yes

Don’t Know

4. In the past year, approximately how many unduplicated HIV-positive clients did your agency serve?: *

(Note: This includes all new and on-going clients)

5. In the past year, how many of the HIV-positive clients served by your agency/program were racial or ethnic minorities?:

6. What is the gender breakdown of the HIV-positive clients served by your agency?

% Male:

% Female:

% Transgender:

7. Do you have a peer program now?: *

Yes (If yes, go to Q. 8 and 9, if no then proceed to next section)

We define peer with the following criteria “an HIV positive person who is a non-clinician and comes from the affected communities with HIV”and helps other people with HIV prevention, care and treatment.

8. How are peers involved in you organization? (Check all that apply):

Peer housed in one organization and out posted to other organizations/sites

Peer employed in house with direct client interaction

Peer is volunteering in house with direct client interaction

Peer is providing program input and feedback regarding patient care, quality improvement, program design and development, etc

Other

If other, please describe: