1 Participant Information Form

OMB No. 0915-0281
Expires:

PIF

HRSA AIDS Education and Training Centers
PARTICIPANT INFORMATION FORM
Please completely fill in the circles (●) when answering the questions below.

1. To create your unique ID number, use the month of your
birth, day of your birth, and last four digits of your SSN. For example,
May 29, 123-345-6789, has the ID number 05296789.

7. Is the employment setting a faith-based organization?
O Yes

O No

O Don’t Know

8. Does the employment setting receive Ryan White CARE Act
funding?
M

O Yes
O No
O Don’t Know
If you don’t know, please write the full name of your employer:

M D D # # # #
Birth
Last 4 SSN
Unique ID Number

_______________________________________________________________

2. Today’s Date (mm/dd/yy)
/
/
mm
dd
yy
3. Your Primary Profession/Discipline (Select one)
O Dentist
O Other Dental Professional
O Nurse Practitioner
O Other Advanced Practice Nurse
O Nurse
O Pharmacist
O Physician
O Physician Assistant

9. Are you of Hispanic, Latino/a, or Spanish origin?
O Yes

10. Your Racial Background (Select all that apply):

O Clergy/Faith-Based Professional
O Dietitian/Nutritionist
O Health Educator
O Mental Health Professional
O Public Health Professional
O Social Worker
O Substance Abuse Professional
O Other (specify): __________________

O Intern/Resident
O Researcher/Evaluator
O Student/Graduate Student
O Teacher/Faculty
O Other (specify): __________________

5. Your Principal Employment Setting (Select one)

Clinic
O Academic Health Center
O Community Health Center
O Family Planning
O HIV Clinic
O Hospital-Based Clinic
O Indian Health Services/Tribal
O Infectious Disease
O Maternal/Child Health
O Mental Health
O Rural Health
O Sexually Transmitted Disease
O Substance Abuse

O American Indian/Alaska Native
O Asian
O Black or African American

11. Your Gender:
O Female

Other Settings
O College/University
O Community-Based Organization
O Correctional Facility
O HMO/Managed Care Organization
O Hospital/ ER
O Military/VA
O Private Practice
O State/Local Health Department
O Non-Health
O Other Primary Care
O Not Working (skip to item 9)

O Rural

O Suburban

O Male

O Transgender

12. Do you provide services directly to clients/patients?
O Yes

O Yes

O No [Stop here. You are done with this form.]
O No/Don’t Know [Stop here. You are done with this form.]

14. How many years have you been providing services directly to
HIV-infected clients/patients? [Round up to the nearest whole year.]

15. Estimate the NUMBER of HIV-infected clients/patients to whom
you provide direct services in an average MONTH.
O None [Stop here. You are done with this form.]
O 1-9
O 10-19
O 20-49
O 50+

For questions 16-18, estimate the PERCENTAGE of your HIV-infected
clients/patients in the past YEAR who were:
16. Racial or Ethnic Minorities
O None

O 1-24%

O 25-49%

17. On Antiretroviral Therapy
O None

18. Women
O None

6. Primary Employment Setting/Zip code
a.

O Native Hawaiian/Other Pacific Islander
O White

13. Do you provide services directly to HIV-infected clients/patients?

4. Your Primary Functional Role (Select one)
O Administrator
O Agency Board Member
O Care Provider/Clinician
O Case Manager
O Client/Patient Educator

O No

O 50-74%

O ≥75%

O 1-24%

O 25-49%

O 50-74%

O ≥75%

O 1-24%

O 25-49%

O 50-74%

O ≥75%

O Urban

b.

Zip code
For Office
Use Only

February
2007

AETC

Sub-site

Program ID

Agency

Ryan White CARE Act
O
O
Yes
No