NEW YORK STATE CONDOM (NYSCondom) PROGRAM

PLEASE NOTE: As of January 1st, 2019, the New York City Condom Program will be fulfilling all requests for safer sex supplies for all New York City-based organizations. After January 1st, previously registered NYC-based organizations will be unable to request safer sex supplies from the New York State Condom Program website. They will need to go to: NYC Condom for safer sex supplies. Thank you.

Organization Information and Attestation

Fields with an asterisk (*) are REQUIRED

Organization Information

Organization Name*

Organization Web Site (If any)

Individual Authorized to Order Supplies must supply unique email addresses for each person listed

First Name*

Last Name*

E-mail Address*
This e-mail address will be your ID for placing NYSCondom orders

Title*

Address Line 1*

Address Line 2

City*

State*

Zip*

Phone Number*
(999)999-9999

Extension:

Fax Number
(999)999-9999

Additional Individual Authorized to Order Supplies must supply unique email addresses

Check If you want to add a second individual authorized to order supplies

First Name

Last Name

E-mail Address
This e-mail address will be your ID for placing NYSCondom orders

Title

Address Line 1

Address Line 2

City

State

Zip

Phone Number
(999)999-9999

Extension:

Fax Number
(999)999-9999

Additional Individual Authorized to Order Supplies must supply unique email addresses

Check If you want to add a third individual authorized to order supplies

First Name

Last Name

E-mail Address
This e-mail address will be your ID for placing NYSCondom orders

Title

Address Line 1

Address Line 2

City

State

Zip

Phone Number
(999)999-9999

Extension:

Fax Number
(999)999-9999

Organization Type: (Check all that apply)*

HIV/AIDS/STD-focused Not-for-Profit/Community-Based Organization

Other Not-for-Profit/Community-Based Organization

Health Care Provider

Mental Health

Substance Abuse Treatment

Social Services

Educational

Criminal Justice/Corrections

New York State Department of Health

Other State Government Agency

City or County Department of Health

Other Local Government Agency

Other:(Specify)

During which of the following service do you intend to distribute safer sex supplies: (Check all that apply)*

HIV/AIDS/STD Education/Prevention

HIV Counseling and Testing

STD Screening

Health Care

Case Management

Health Education

Other Education

Mental Health

Substance Abuse Treatment

Substance Use-Related Counseling

Syringe Access

Faith-Based or Spiritual

Family Planning

Sexual Health Counseling

Housing Assistance

Legal

Criminal Justice/Corrections

Support Groups

Outreach

Entitlements Counseling/Facilitation

Youth Development

Services for victims of domestic violence and sexual assault

Nutritional Services

Transportation

Recreation/Social

Other:(Specify)

Condom Distribution Information

Identify populations to which you anticipate 10 percent or more of safe sex supplies ordered through NYSCondom will be furnished. (Check all that apply)*

Gay men/men who have sex with men

Lesbians/women who have sex with women

Heterosexual men

Heterosexual women

Transgender male-to-female

Transgender female-to-male

Injection drug users

Other drug users

Sex workers

Clients of sex workers

Organization clients/patients/participants

13-18 Year Olds

18-24 Year Olds

Persons 50 years of age or older

Homeless and marginally-housed individuals

Immigrants

Migrant Workers and their families

Persons in rural communities

Probationers or parolees

Special event attendees

Other:(Specify)

How will you distribute these supplies? *

On-site

Off-site

On-site and Off-site

What are the multi-county regions you will be distributing supplies in?(Check all that apply)*

Binghamton/Southern Tier
(Broome, Chenango and Tioga counties)

Buffalo/Western New York
(Allegany, Cattaraugus, Chautauqua, Erie, Genesee, Niagara, Orleans, and Wyoming counties)

Long Island
(Nassau and Suffolk counties)

Lower Hudson Valley
(Putnam, Rockland and Westchester counties)

Mid-Hudson Valley
(Duchess, Sullivan, Ulster and Orange counties)

Northeastern/Albany
(Albany, Clinton, Columbia, Delaware, Essex, Franklin, Fulton, Greene, Hamilton, Montgomery, Otsego, Rensselaer, Saratoga, Schenectady, Schoharie, Warren, and Washington counties)

Rochester/Finger Lakes
(Chemung, Livingston, Monroe, Ontario, Schuyler, Seneca, Steuben, Wayne and Yates counties)

Syracuse/Central
(Cayuga, Cortland, Herkimer, Jefferson, Lewis, Madison, Oneida, Onondaga, Oswego, St. Lawrence and Tomkins counties)

New York City

**Note: Supplies may be available for New York City only if NYC Condom cannot fulfill need.

*What are the primary counties in which you will be distributing supplies?(Select at least one)

Select County
Enter Zip/City/Neighborhood for County 1

Select County
Enter Zip/City/Neighborhood for County 2

Select County
Enter Zip/City/Neighborhood for County 3

Select County
Enter Zip/City/Neighborhood for County 4

Select County
Enter Zip/City/Neighborhood for County 5

Knowledge of NYSCondom Program

How did you learn about this program for free condoms?*

My organization has a history of ordering condoms from the AIDS Institute

Brochure or poster

NYS DOH Staff

NYS DOH mailing

NYS DOH Web site

Another website

Specify:

Ryan White Network

HIV Prevention Planning Group

Other

Specify:

Attestation*

By Submitting this online Organization Information and Attestation form, I am attesting to each of the following:

The Information provided above is accurate to best of my knowledge.

All items ordered through this program will be provided free of any charge and without any requirement or obligation on the part of those to whom my organization provides these items.

All of these items will be distributed solely within New York State.

The staff, volunteers and other agents of my organization will not knowingly furnish these items for re-distribution outside of New York State.

Information on the proper use of condoms, either through printed materials or other instruction, will be made readily available to individuals being furnished these items.

I will cooperate with staff from the New York State Department of Health in evaluating this distribution program.

Agree Disagree

The persons listed above on this form have been authorized by the executive director or designee, whose contact information appears below, to request supplies from the New York State Condom Program.

Agree Disagree

Executive Director or Designee Contact Information

Executive Director or Designee Name*

Title*

Phone Number*
(999)999-9999

Extension:

E-mail Address*