farmworker health services inc.

	*farmworker health services, inc.*
	Request FHSI Services

To request the services of FHSI, please complete this form and click submit. FHSI will respond to your request as soon as possible.
Request FHSI Services

I. Contact Information

Name of Organization:

Address:

*City:

*State:

*Zip:

*Name of Contact Person:

*Title:

*Phone:

Fax:

*Email:

II. Program Information

1. Total number of years with outreach services:

2. Do you have an Outreach Coordinator or Director?
Yes
No

7. How many farmworkers have you served over the past three years? (Please answer to the best of your ability. For 330(g) grantees, this data can be found on your UDS report).
2006

2005

2004

III. Support Service Needs

1. In what ways are you working to increase your farmworker client numbers and expand services to them?

2. Please describe any staffing, programmatic, or technical difficulties/challenges that hinder your ability to provide outreach or other services to farmworkers:

3. Please list the desired outcomes of formal collaboration with FHSI:

How can FHSI best provide this support? (Choose all that apply)
On-site consultation
Off-site consultation (email, telephone, fax)
On-site training
Regional training (involving other organizations)
Other:

We kindly requests that you also submit a cover letter from your CEO stating your interest in FHSI’s services. The letter should be faxed to: Kristen Stoimenoff, Director of Training & Consultation, at 202-347-6385.