1 Event Record

Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this project is 0915-0281 and the expiration date is 07/31/2013. Public reporting burden for this collection of information is estimated to average .007 hours per respondent annually, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 10-29, Rockville, Maryland, 20857.

HRSA AIDS Education and Training Centers

EVENT RECORD

1. Date of Event (mm/dd/yy) 2. Name of Event: / / ____________________________

3. Training Location Zipcode

mm dd yy

4. Topics (Fill in the bubble to the left of ALL topics covered in the program.)

6. What other organizations helped with this event? (Select all that apply.)

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Clinical Management

Adherence

Antiretroviral Treatment

Non-ART Treatment

Basic Science/Epidemiology

Clinical Manifestations of HIV Disease

Co-Morbidities

HIV Routine Laboratory Tests

Hepatitis A, B, C

Nutrition

Opportunistic Infections

Oral Health

Pediatric HIV Management/ Perinatal Transmission

Pre/Post-Exposure Prophylaxis, (Occupational & Non-Occupational)

Reproductive Health

Resistance/ Genotype-Phenotype Interpretation

Routine Primary Care Screenings

Health Care Organization and Delivery Issues

Agency Needs Assessment

Community Linkages

Cultural Competence

Education Development/Delivery

Grant Issues

Health Literacy

Healthcare Development/ Clinical Service Coordination

Healthcare Organization and Finances

HIPAA/Confidentiality

Quality Improvement

Resource Allocation

Technology

Prevention and Behavior Change

Risk Assessment

Risk Reduction/Harm Reduction

Routine HIV Testing

Psychosocial Issues

Mental Health

Substance Abuse

Targeted Populations

Adolescent (Ages 13-24)

Children (Birth – 12)

Gay/Lesbian/Bisexual/Transgender

Homeless/Unstably Housed

Immigrant/Border Populations

Incarcerated Individuals

People Over 50 Years of Age

Racial/Ethnic Minorities

Rural Populations

Women

Other Population _______________________

O None

Other AETCs

O Delta

O FL/Caribbean

O Midwest

O Mtn. Plains

O New England

O NY/NJ

O Northwest

O Pacific

O PA/Mid-Atlantic

O Southeast

O Tx/OK

O Ntl. Clinicians’ Consult. Ctr.

(NCCC)

O Ntl. Multi-Cultural Ctr.

O Ntl. Resource Ctr. (NRC)

O Ntl. Evaluation Ctr.(NEC)

O CBA For CHCs

Other Training Centers

O Addiction Technology Transfer Center (ATTC)

O Area Health Education Center (AHEC)

O Prevention Training Center (PTC)

O Regional Training Center (RTC)

O TB Training Center

Other Agencies

O AIDS Community-Based Organizations

O College/University/Health Professions School

O Faith-Based Organization

O Community Health Center

O Historically Black College or University/

Hispanic Serving Institution/Tribal College or

University

O Hospital/Hospital-Based Clinic

O Agencies funded by Ryan White Program

O Tribal Health Organizations

O Corrections

7. # of Participants

8. # PIFs collected

9. Length of Session

Total Hours of Event: Fill in hours of event to the nearest quarter hour;

.25 = ¼ ; .50 = ½ hour; .75 = ¾ hour

Level I Didactic Presentation . .

Level II Skills Building . .

Level III Clinical Training .

L evel IV Group Clinical

Consultation . .

L evel IV Individual Clinical

Consultation . .

Level V Technical Assistance . .

10. Select the training modalities or technologies that were applied in the event.

(Select all that apply.)

O 1. Chart/Case Review O 6. Role Play/Simulation

O 2. Clinical Preceptorship/Mini-Residency O 7. Self-Study

O 3. Computer –based O 8. Telemedicine

O 4. Conference call/Telephone O 9. Webcast/Webinar

O 5. Lecture/Workshop

5. Were any funds from the following initiatives used to support this event?

O 1. American Indian/Alaska Native O 3. Minority AIDS Initiative (MAI)

O 2. Border Health Initiative O 0. None of the above

Office Use

Only

AETC

LPS

Agency

Program ID