HIV prevention supplies request

                                        STI/HIV Prevention Supplies Request
Note: The following supplies may be only be ordered and used for STI/HIV prevention activities occurring in the State of Kansas. In requesting prevention supplies from KDHE the agency/organization/group agrees to supply distribution information back to KDHE on at least a quarterly basis via the appropriate tracking form.

Shipping of items is subject to availability. Submitting a request for materials does not guarantee shipment of materials. KDHE reserves the right to limit availability of items based on the needs of agencies funded to do STI/HIV prevention activities, as well as for other reasons. If you have questions, please contact STI/HIV Prevention Program at 785-296-5595 or 785-296-7716.
*Denotes required fields
 
*Agency/Organization or Affiliation:

 
*Contact Person:

 
*Shipping Address:

 
*City:

 
*State:

 
*Zip Code:

 
*Email: 

Which of the following locations do you intend to distribute the requested materials? (Check all that apply)
STI/HIV testing clinic
Family Planning Clinic
Health Fair
School
Outreach Location
Other (please describe): 

Which of the following populations do you intend to be the primary recipients of the materials? (Check all that apply)
People living with HIV and/or their sexual partners.
Men who have sex with men(including gay, bisexual, and transgender men).
African-American women.
Youth between the ages of 15 to 24.
Injection drug users.
STI/HIV testing clinic patients.
Other (please describe). 

Supplies:
 
Dental Dams, Assorted Flavors (order in quantities of 10, limit 50 per order).

 
Female Condoms (order in quantities of 10 limit 100 per order).

 
Lube, Water-Base Assorted  (order in quantitites of 10, limit 100 per order).

 
Lube, Silicone-Base (order in quantities of 10, limit 100 per order).

 
Male Condoms, Latex, Assorted (order in quantities of 50, limit 300 per order).

 
Male Condoms, Assorted Flavors (order in quantities of 50, limit 100 per order).

 
Male Condoms, Latex, Assorted LARGE Size (order in quantities of 50, limit 100 per order).

 
Male Condoms, Latex, One Brand (order in quantities of 50, limit 300 per order).

Male Condoms, Non-Latex (order in quantities of 50, limit 100 per order).

 
Condom Compacts, Assorted Colors (order in quantities of 5, limit 30 per order). 

 
Bracelets, Red “Get Tested” (order in quantities of 5, limit 25 per order).


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