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National Prevention Information Network

Styles are currently disabled or not supported by your browser. If you experience any issues submitting organization information updates, please contact NPIN at info@cdcnpin.org for assistance. Please include your name, phone number, organization’s name, organization’s address, NPIN organization number (if known) and summary of your request.

Name of the Organization:
 *

Program Name:
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Address:
Country: *
Street Address 1: *


e.g. 123 Main St
Street Address 2:


e.g. Ste 100, Bldg 123
ZIP Code: *


e.g. xxxxx-xxxx
City: *
State: * 
Primary web site address: Social media:
Comment:
e.g. www.cdcnpin.org
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E-mail:
Comment:
e.g. abdc@xxxxx.xxx
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Phone Type: *Phone: *   Ext:
Comment:
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Submitter:
                  First Name: *
              M.I:
about information
The following information will not be accessible to anyone other than NPIN staff.

NPIN staff will use this information to periodically update your organization information.
About This Information
Last Name: *
Job Title:
Main Phone: *

Ext:
E-mail Verification *
 
Re-enter e-mail address to verify:  *
 
 
    
Primary Contact:
First Name:
M.I:
Last Name:
Job Title:
Main Phone:
Ext:

E-mail Verification Address:
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Is your organization a clinic?*
Services Offered (required) Other Services:

Organization Type:*
Legal Status:*
Hours of Operation:*
Monday Through
Tuesday Through
Wednesday Through
Thursday Through
Friday Through
Saturday Through
Sunday Through
Comments:
About Services:
Service Level:*
Fee Information:*
Appointment Required:*
Eligibility:
Services Offered: *
Testing Services:
Services Offered (required) Testing Services
HIV Testing:
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STD Testing:
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Viral Hepatitis Testing:
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TB Testing:
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Services Offered (required) Free Testing Services
Free Testing Services:
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Services Offered (required) Prevention Education, Medical Treatment, or Support Services
Prevention Education Service:
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Medical Treatment Services:
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Support Services:
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Services Offered (required) Additional ServicesAdditional Services:




Other Services:
In the box below, please list any other specific HIV/AIDS, STD, Viral Hepatitis, or TB-related prevention, financial, information, medical, support, counseling or research services provided by your organization.
Services Offered (required) Other Services:

Main Target Populations: (required)*
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Main Target Population (required) Additional Target Population(s)








Additional Target Population(s)



Others:

Languages: (required)*
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Language(s) (required)
Others:

General Comments: