Database Update Form 
Name:
URL:
Address: E-mail:
Organization:
Phone:
Title: Fax:
Date: Hotline:
1. Please include me in your:   Mailing List   Expert Database 
2.  I agree to make my contact info available on your website?  Yes     No
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Job Function
Steering Committees
Scope of Work
ED/President
Board
Consultant/Functional
Elected Gov. Official
Government Official
I am interested in
 Research
Training & Tech. Assistance
 Community Development
 Policy
I am a:
Steering Cte. Member
Steering Cte. Ex-member
 Local
 State
 Regional
 Federal   National
International
Other:
        My organization offeres the following services to Latinos/as
Services to Latinos
 Culture Specific
Bilingual Staff
 Materials in Spanish
 Interpretation
All Services
 Immigrants
Other Cultures
Latino Population Served
76-100 %
51-75 %
26-50 %
 0-25 %
My individual type of work:

Social Worker
Hotline Staff
Community Educator
Program Staff
Management
 DV Advocate

Mental Health
 General
 Victims
 Batterers
Children
Substance Abuse
 Sexual Assault
Worker

Medical
Doctor
Nurse Practitioner

Legal
Attorney
Legal Advocate
General
Family
Immigration
Criminal

Law Enforcement
Probation
 Police
 Prosecutor
Judge
Other Domestic Violence
DV Non-direct
 DV Allied
DV Direct
Policy Advocacy
 Trainer
Researcher
Professor
Student
Religious
Media
Dev./Fundraiser
Grant Foundation
Organization Work and Services
 
Type of Organization
Activist Organization
BIP
Children's Organization
Congress
DV Clearinghouse

        and/or Resource Center
DV Organization
DV Research Organization
DV State Coalition
Educational Institution
Federal Government
Foundation
Government Agency
Gov. Agency Involved in DV
Hispanic/Latino DV Org.
Hispanic/Latino Org.
International Org.
Judicial System
 LAV Grantee
Law Enforcement Focused on DV
Law Enforcement not Focused
Media
Men's Organization
 National Allied Issue
National DV
 National Latino

Religious Organization
State Administrators
State Coalition
State Government
State Legislature
Training/Technical Assist. Org.
VAWO State Administrators
VAWO Technical Assist. Provider
Women's Organization

Types of Services
DV
 DV and others
Case Management
Hotline
Individual Counseling
Support Group
Police
Medical
Court
Probation
Shelter
Transit Housing
Employment Assistance
 Benefits Assistance
Community Education
Substance Abuse
Sexual Assault

Family Planning
General HC
Mental Illness
HIV
 Legal Advocacy
Attorney
General Law
 Family Law
 Immigration Law
Restrain Orders
Criminal Law
All Law
Other:
 

Population Served
 Survivors
Batterers
 Minor Children
Youth
Women
Men
 Family
General
Elders
Transgender
Gay
 Serves All

Or fax: (703) 449-9774
 

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