Interventions

Safe in the City kit (order form)

Order your copy of the Safe in the City kit

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 clinics will receive first priority for kit shipment. Due to limited supply, we provide one kit per agency.

STAY TUNED--COMING THIS SUMMER--There will be a kit request form tailored for CBOs requesting SITC as an alternate video for the VOICES/VOCES intervention or as a stand-alone waiting room video.  

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)?
 
8.

Do you anticipate your agency will need technical assistance in order to increase readiness to implement SITC?
  Yes
  No
  Not Sure

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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