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 09/30/2016. 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
Instructions: This form should be completed by the program office or trainer that sponsored the training event.
Name of Event: ________________________________________________
1. AETC Number:
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2. Local Partner number:
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3. Event Date:
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4. ZIP code where event occurred (for live online events, use state where event was hosted):
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5. Program ID Number:
The program ID number is a unique number generated by the AETC to identify the event.
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6. List the unique identifiers for all participants of the event.
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For questions 7 through 12, check to indicate whether each topic was covered in the event.
7. HIV prevention
Behavioral prevention
Harm reduction / safe injection
HIV transmission risk assessment
Postexposure prophylaxis (PEP, occupational and nonoccupational)
Preexposure prophylaxis (PrEP)
Prevention of perinatal or mother-to-child transmission
Other biomedical prevention
8. HIV background and management
Acute HIV
Adult and adolescent antiretroviral treatment
Aging and HIV
Antiretroviral treatment adherence, including viral load suppression
Basic Science
Clinical manifestations of HIV disease
HIV diagnosis (i.e. HIV testing)
HIV epidemiology
HIV monitoring lab tests (i.e. CD4 and viral load)
HIV resistance testing and interpretation
Linkage to care
Pediatric HIV management
Retention and/or re-engagement in care
9. Primary Care and Co-morbidities
Cervical cancer screening, including HPV
Hepatitis B
Hepatitis C
Immunization
Influenza
Malignancies
Medication-assisted therapy for substance use disorders (i.e.e buprenorphine, methadone, and/or naltrexone)
Mental health disorders
Non-infection comorbidities of HIV or viral hepatitis (i.e. cardiovascular, neurologic, renal disease)
Nutrition
Opportunistic infections
Oral health
Osteoporosis
Pain management
Palliative care
Primary care screenings
Reproductive health, including preconception planning
Sexually transmitted infections
Substance use disorders
Tobacco cessation
Tuberculosis
10. Issues related to care of people living with HIV
Cultural competence
Health literacy
Motivational interviewing
Stigma or discrimination
Low English proficiency
11. Education
Adult learning principles
Best practices in training
Curriculum development
Use of technology for education (i.e. webinar development)
12. Health care organization or systems issues
Billing for services and payment models
Case management
Community linkages
Confidentiality / HIPAA
Coordination of care
Funding or resource allocation
Health insurance coverage (i.e. Affordable Care Act, health insurance exchanges, managed care)
Legal issues
Organizational infrastructure
Organizational needs assessment
Patient-centered medical home
Practice Transformation
Quality Improvement
Team-based care (i.e. interprofessional training)
Use of technology for patient care (i.e. electronic health records)
13. Did the event address any of the following target populations?
Children (ages 0 to 12)
Adolescents (ages 13 to 17)
Young adults (ages 18 to 24)
Older adults (ages 50 and over)
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Pacific Islander
Other race / ethnicity (specify: __________________)
Women
Gay, lesbian, bisexual or transgender
Homeless or unstably housed
Incarcerated or recently released
Immigrants
U.S.-Mexico border population
Rural populations
Other special population (specify: ________________)
14. Which other AETCs collaborate to organize the event?
Frontier AETC
Mid-Atlantic AETC
Midwest AETC
New England AETC
Northeast Caribbean AETC
Pacific AETC
South Central AETC
Southeast AETC
AETC National Clinicians’ Consultation Center
AETC National Coordinating Resource Center
AETC National Evaluation Center
Same region but different local partner (enter LP number): ______
Duke NP program
Johns Hopkins NP program
Rutgers NP program
SUNY PA program
UCSF NP program
15. Which other federally-funded training centers collaborate to organize the event?
Addiction Technology Transfer Center (ATTC)
Area Health Education Center (AHEC)
Capacity Building Assistance (CBA) Provider
STD Clinical Prevention Training Center (PTC)
TB Regional Training and Medical Consultation Center
Viral Hepatitis Education and Training Project
Public Health Training Center (PHTC)
Family Planning National Training Center
16. Did any other organizations collaborate to organize this event? Check yes or no.
AIDS services organization
Other community-based organization
Health professions school
Faith-based organization
Community health center, including federally qualified health center (FQHC) funded by HRSA
Historically Black College or University
Hispanic-Serving Institution
Tribal College or University
Hospital or hospital-based clinic
Ryan White HIV/AIDS Program-funded organization, including subrecipients
Tribal health organization
Correctional institution
Other (specify: ____________________________)
17. Number of hours for each type of training or technical assistance modality for the event. Enter hours rounded to the nearest ¼ hour in each cell (.25 = ¼, .50 = ½ hour, .75 = ¾ hour). Do not enter data into cells that contain “not applicable.”
Training and TA Modality |
In-person |
Distance-based (live) |
Distance-based (archived) |
Didactic presentations |
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Interactive presentations |
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Not applicable |
Communities of practice |
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Not applicable |
Self-study |
Not applicable |
Not applicable |
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Clinical preceptorships |
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Not applicable |
Clinical consultation |
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Not applicable |
Coaching for organizational capacity building |
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Not applicable |
18. Were continuing education credits made available to trainees?
Yes No
19. Indicate which of the following sources of funds were used to support this event.
Core Training and Technical Assistance
Practice Transformation
Interprofessional Education
Minority AIDS Initiative (MAI)
CDC
| File Type | application/msword |
| File Title | Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of infor |
| Author | FMalitz |
| Last Modified By | SCrooks |
| File Modified | 2016-01-22 |
| File Created | 2016-01-22 |