Reach CNY (Central New York)
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Resources, Education, Advocacy and Collaboration for Health

Online Form C

New York State Department of Health
AIDS Institute - HIV Education & Training Programs
Demographic Reporting Form for Authorized Training Agency (ATA)

Estimated Data on Participants (Submit one form per training)

Email Address:
Presentation Date:
Presenters:
Authorized Training Agency Name:
Title of Presentation:
Length of Presentation:
Training Site (Include City and County):
Total Number of Participants:
 
Characteristics of Participants (Insert Totals)
 
Gender:
Male:
Female:
Transgender: Unknown:
 
Age:
<12:
12 - 19:
> than 19: Unknown:
 
Race:
White (non-Hisp):
Black (non-Hisp):
Hisp:
Asian/PI: Native Am: Other:
Unknown:
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