HIV Counselling and Testing Request Form

Company name *

Business Type Private/Business
Public/Government
Academic/Research
International Organisation
NGO/Community Organisation
Secondary/Tertiary Educational facilities
Other

Name *

Designation

Mobile Number

Office Number

Email Address *

Date ...

Time

Physical Address/Venue

Directions to Venue

GPS Coordinates of Venue

Name

Designation

Mobile Number

Office Number

Email *

Number of Employees Targeted for HCT Campaign *

Number Insured *

Number Uninsured *

Medical Scheme Name

Is the HCT event part of a workplace HIV program? Yes No

Will awareness campaign be completed before HCT date? Yes No

Is secure parking available for the mobile unit? Yes No

Is there adequate space for vehicle and tent village? Yes No

Is office space available for conducting HCT Services? Yes No

Will refreshments and or lunch be provided/available for HCT team members? Yes No

Remarks/Special Requests