First Name:             Middle Initial:

Last Name:    

Organization:       

Dept:             

Title:                        

                   Check if 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

1. Check off the update you want to attend.           

NYC, April 29, 2010, 9am—12pm         

Syracuse, May 21, 2010, 9am—12pm    

Syracuse ATA Teleconference     

2. Number of Years in Current Occupation:
    Please Select One 0-1 2-4 5-7 8 or more

3. 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

4. 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

5. Educational Level:
    Please Select One Less than 12 years High School/GED College 1 College 2 College 3 College 4 Graduate Degree

6. Ethnicity:
    Please Select One Hispanic or Latino Not Hispanic or Latino

7. Race:
    Please Select One American Indian or Alaskan Native Asian Black or African American Native Hawaiian or Pacific Islander White More than one race Unknown/Unreported                                      

Thank You

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