Contact Name: |
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Contact Phone: |
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Contact Email Address: |
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Contact Person for Latino Services: |
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Contact Phone: |
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Contact Email Address: |
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Name of Organization: |
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Name of Project: |
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Mailing Address: |
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Shipping Address: |
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# of Staff
# of Volunteers |
| Web Site URL (if applicable) |
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| Size of Organization Budget: |
Less than $100,000
$100,000 - $299,000
$300,000 - $499,000
$500,000 - $1M
More than $1M
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Tell us about your organization: |
1. Please share a brief overview of the mission of your organization and programs/services provided: |
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2. List the counties you serve: |
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3. Describe your clients (age, race/ethnic background, income, educational level, women, men, children, pregnant women): |
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| With regard to client description by race, please list the percentages of each: |
| African American |
% |
| White Hispanic |
% |
| Hispanic |
% |
| Other: |
% |
| Estimated number of clients below poverty line: |
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| 4. Do you provide services to Latinas? |
YES
NO
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| If yes, please describe: |
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5. Please list any community-based organizations that you partner with, on women's health issues, who you feel would benefit
from involvement in the RICHES project (they will be invited to participate and could get information on funding, resources, materials, be added to our database, etc.) |
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| 6. What is your preferred method for receiving information? |
Mail
Email
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7. Do you use the internet regularly? |
YES
NO
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8. If you do not provide services to Latino women and are interested in accessing this population,
please describe the major barriers for your agency: |
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9. Does your organization: |
Create educational materials on women's health topics? |
YES
NO
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Distribute educational materials on women's health topics? |
YES
NO
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| If YES to either, check what types of materials are distributed: |
Preparing for pregnancy
Health during pregnancy
Contraception
Smoking Cessation
Substance/alcohol abuse
HIV/AIDS and STDs
Stress
Other |
| If Other, please list: |
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If YES to either, would you be willing to share copies to include in a statewide toolkit? |
YES
NO |
If YES to either, do you provide materials in languages other than English? |
YES
NO |
| Please list: |
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10. If a regional meeting is scheduled in your area, or for the future planning of the project, what types
of information would make it a valuable meeting to you? (Check all that apply and add to this list) |
Educational resources on women's health topics
Funding sources
Grant writing
Networking and learning about other community-based agencies
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Best practice models for provisions of women's health
Raising awareness of your program/issues in your community (media)
Developing materials for your program |
| Other topics (list): |
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11. If you were invited to a regional meeting, how far would you be willing to travel? |
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# of miles
# of hours |
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