Safe in the City kit (order form)

Order your copy of the Safe in the City kit

PLEASE NOTE: The current inventory of Safe in the City kits is nearly depleted. Most likely, by August 2009, we will no longer be able to ship Safe in the City kits and we will remove the order form from this website. Instead, you will need to download all the materials from this website. The video itself will be password-protected on this site and you will be asked to provide some basic contact information to receive the password.

If you are interested in obtaining a copy of the Safe in the City kit, which includes a 23-minute educational DVD, a display poster, and User's Guide, please complete and submit the form below. Please note: STD, Health Services and Family Planning clinics, will receive first priority for kit shipment. Due to limited supply, we provide one kit per agency.

Before placing your Safe in the City kit order and for the status of a previous kit order, please read the following important information. Click here. 

  

1. Please identify your agency type:*
 
 
 
 
 
 
 
 
 
2. What kind of programming is currently available in your agency’s waiting room? (please check all that apply)
 
 
 
 
3. What is the average wait time in your agency’s waiting room?
 
 
 
 
4. How ready is your agency to implement SITC?
 
 
 
 
 
5.

Please indicate which of the following factors apply to your clinic. (check all that apply)
 
      If "No," will this be a barrier?
  Yes No Yes No
My agency has a television
   
    Yes No Not Sure
6. Do you anticipate needing administrative approval to incorporate SITC into your clinic?
 
 
    Yes No Not Sure
7. Do you anticipate needing approval to install necessary equipment (i.e. TV, DVD player, posters)?
 

Requester's Contact Information
First Name: *
Last Name: *
Organization Name: *
Address 1: *

Note: We cannot deliver to P.O. boxes or P.O. ZIP codes.
Address 2:
City *
State: *
Country:
Zip: *
Phone: *
E-mail: *
Please provide the contact information for the person that is responsible for showing the video to clinic clients.
First Name: *
Last Name: *
Title: *
Phone: *
E-mail: *
 
Additional Information: (800) 462-9521 or (202) 884-8712
E-mail: interventions@aed.org
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