Form Test

Request to Adapt LARC Materials

Name *

E-Mail *

Position

Project

Organization

Phone

Please specify which materials you wish to use (check all that apply): Brochure with photosBrochure with illustrationsPoster series (6 posters)Discussion guideVideo

Please describe how and by whom materials will be used (e.g., posters will be posted in clinics or pharmacies, health workers will use the brochure as job aides, etc.)

I/my project/my organization request(s) HC3’s permission to (select one of the following): Select oneOption 1: Use the LARC materials as is - e.g. otherwise making no changes to materials’ language images marking or branding) - but will add project/organization logos to the materials before reproducing and disseminating.Option 2: Adapt or alter the materials’ language and images in any way to best suit my country or project context.

If you selected Option 1 above, please specify logos that will be added.

If you selected Option 2 above, please specify the planned adaptations (e.g., translation, changing phrasing, adding/deleting content, etc.):

I acknowledge that selecting Option 2 means I will remove both HC3 and USAID logos from the materials before reproducing and disseminating, and will include in their place the following text: These materials were adapted from USAID-funded materials created under the Health Communication Capacity Collaborative (HC3) Project, made possible by the support of the American People. The contents of this adapted material do not reflect the views of USAID or the United States Government. The original materials can be found here: http://healthcommcapacity.org/technical-areas/family-planning/long-acting-reversible-contraceptives-larcs/

I will share with HC3 a copy of the revised materials.

4 + 2 = ? Please prove that you are human by solving the equation *