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HACU- Educational Material and Resources Request Form
This form seeks to fulfill requests for brochures, lubricants, condoms and HIV self-testing kits.
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* Indicates required question
Name of Organization
*
Your answer
Requestor Name
*
Your answer
Position in Organization
*
Your answer
Name of Event
*
Your answer
Frequency of Event
*
One-time
Monthly
Bi-monthly
Quarterly
Semi-annually
Other:
Date of (1st) Event
*
MM
/
DD
/
YYYY
Target Audience
*
MSM
FSW
General Adult Population
Adolescents
Other:
Required
Name of Items Requested
*
Brochures
Lubricants
Male Condoms
Female Condoms
HIV Self-Testing Kits (HIVST)
Required
Quantity of Brochures Requested
Your answer
Quantity of Lubricants Requested
Your answer
Quantity of Male Condoms Requested
Your answer
Quantity of Female Condoms Requested
Your answer
Quantity of HIVST Requested
Your answer
Name of Person Collecting Items
*
Your answer
Contact Number
*
Your answer
Email Address
Your answer
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This form was created inside of Ministry of Health - Trinidad and Tobago.
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