Health Professional Application for Training

Capacity Building Assistance Program: Assessment and Quality Control

Att 3 HPAT-wordversion_approved Feb 2016

Att 3_Health Professional Application for Training (HPAT)

OMB: 0920-1099

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Form Approved

OMB No. 0920-1099

Exp. Date: 02/28/2019


Health Professional Application for TrainingPlease print clearly


The requested information is used only to process your training registration and will be disclosed only upon your written request. Continuing education credit can only be provided when all requested information is submitted.



Today’s date________________

Course title________________________________ Course date________________________


First name____________________ Middle Initial_________ Last name___________________________

Degree_________________________ Title/Position__________________________________________

Organization__________________________________________________________________________

Address______________________________________________________________________________

City____________________________ State______ Zip_________ Country (if not US)_______________

Daytime Phone_______________________ Alt Phone ________________ E-mail _________________



Your Unique ID number is the first two letters of your first name, the first two letters of your last name, the month of your birth, and the day of your birth. For example: John Smith, May 29 would be JOSM0529.











FN

FN

LN

LN


M

M

D

D


UNIQUE IDENTIFIER

1. Your primary profession/discipline (select ONE)

Dentist

Other dental professional

Advanced practice nurse

Registered nurse

Licensed practical nurse

Pharmacist

Physician

Physician Assistant

Criminal justice/recovery

specialist

Dietitian/Nutritionist


Epidemiologist

Health education specialist


Clergy/Faith-Based Professional

Dietitian/Nutritionist

Health Educator

Mental/behavioral health

professional

Social worker


Substance abuse professional

Community health worker

Other

(please specify)_____________


2. Your primary functional role (select ONE)

Administrator (director, coordinator, manager, supervisor)

Agency Board member

Clinician/Care provider

Case manager

Client/patient counselor

Client/patient educator

Clinical/medical assistant

Disease intervention specialist / Partner services provider

Intern /resident

Mental/behavioral health therapist

Outreach staff

Peer support provider

Researcher / evaluator

Student/Graduate Student

Teacher / faculty

Trainer / TA Provider

Other (please specify)_____________________


Public reporting burden of this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. 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. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; Attn: OMB-PRA (0920-1099)


3. Your principal employment setting (select ONE):

Academic Health Center

College/University

Community-based service organization (CBO)

Community health center (e.g. Federally Qualified Health Center)

Other non-profit health center

Community/retail pharmacy

Correctional facility

HMO/managed care organization

Hospital/Hospital-affiliated clinic

Military Health System/ Veterans Health Admin facility

Private practice (Solo/group)

Rural health center

State/local health department

Tribal/Indian Health Service facility

Non-Health Setting

Other: (please specify)

Not working_(Go to question 11)__________

4. Primary programmatic focus of your work (select up to TWO):

HIV/AIDS

STD

TB

Hepatitis

Reproductive health / family planning

Recovery support/ trauma/ domestic violence

Labor and delivery

Adolescent and/or pediatric health

Emergency medicine / urgent care

Primary care (e.g. genera/family medicine)

Mental/behavioral health

Oral health

Other infectious diseases

Other (please specify)_____________________



5. Primary Employment Setting


  1. Rural Suburban/urban


  1. Zip code







6. Is your employment setting a faith-based organization?

Yes No Don’t Know

7. Does your employment setting receive funding from any of these sources (select all that apply)?

  1. Ryan White Program

Yes

No

Don’t know

  1. Title X / Family Planning

Yes

No

Don’t know

  1. CDC

Yes

No

Don’t know

  1. SAMHSA

Yes

No

Don’t know

  1. Minority AIDS Initiative

Yes

No

Don’t know



8. Please write the FULL name of your agency:

_______________________________________



Some programs and organizations provide services to a particular population group. In the following questions, please tell us about the population groups your program or organization serves.



9. Does your program predominantly serve any racial and ethnic minority groups?

Yes (answer question 9a)

No, my program does not focus on any specific racial and ethnic groups (Go to question 10)

Don’t know (Go to question 10)



9a. If yes, select up to TWO of the following racial and ethnic groups that are a focus of your program:

American Indians or Alaska Natives

Hispanics or Latinos/as

Asians

Native Hawaiians or Pacific Islanders

Blacks or African Americans




10. Does your program predominantly serve any special populations?

Yes (answer question 10a)

No, my program does not focus on any specific population groups (Go to question 11)

Don’t know (Go to question 11)



10a. If yes, choose up to THREE of the following populations served by your program:

Adolescents

HIV+ individuals

Homeless individuals

Incarcerated individuals/parolees

Low-income individuals

Men who have sex with men

Men who have sex with men and women

Older adults


Pregnant women

Recent immigrants/refugees/migrants or

seasonal workers

Sex workers

Substance users

Transgender individuals

Women

Other (please specify) _________________


11. What is your racial background? (Select all that apply?)


American Indian or Alaska Native

Native Hawaiian or Pacific Islander

Asian

White

Black or African American



12. Are you of Hispanic, Latino/a, or Spanish origin?

Yes No


13. What is your gender?


Female Male Transgender: Female to male Transgender: Male to female


14. Do you provide services directly to clients or patients?

Yes (Go to question 15)

No (Stop here. You are done with this form.)


15a. Please estimate the PERCENTAGE of your OVERALL CLIENT/PATIENT population in the past YEAR who were racial-ethnic minorities:


None/yr. 1-24%/yr. 25-49%/yr. 50-74%/yr. ≥75%/yr.


15b. Please estimate the PERCENTAGE of your OVERALL CLIENT/PATIENT population in the past YEAR who received routine HIV testing:


None/yr. 1-24%/yr. 25-49%/yr. 50-74%/yr. ≥75%/yr.



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

Yes (Go to question 17)

No (Stop here. You are done with this form.)


17. How many YEARS have you been providing services directly to HIV-infected clients/patients?

Shape2 Shape1

(Round up to the nearest whole year)



18. Estimate the NUMBER of HIV-infected clients/patient to whom you provide direct services in an average MONTH.



None/mo. 1-9/mo. 10-19/mo. 20-49/mo. 50+/mo.



For Questions 19 through 22, estimate the PERCENTAGE of your HIV-infected clients/patients in the past YEAR who are:



19. Racial-ethnic minorities



None/yr. 1-24%/yr. 25-49%/yr. 50-74%/yr. ≥75%/yr.



20. Co-infected with Hepatitis C



None/yr. 1-24%/yr. 25-49%/yr. 50-74%/yr. ≥75%/yr.

21. Receiving antiretroviral therapy

None/yr. 1-24%/yr. 25-49%/yr. 50-74%/yr. ≥75%/yr.

22. Women

None/yr. 1-24%/yr. 25-49%/yr. 50-74%/yr. ≥75%/yr.



Thank you for your valuable time.


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EventID: _____________________

File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleCDC National Network of STD/HIV Prevention Training Centers
AuthorKathryn Koski
File Modified0000-00-00
File Created2021-01-23

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