Form 0920-0995 Att 3 NNPTC Abbreviated HPAT wordversion

National Network of STD Clinical Prevention Training Centers (NNPTC): Evaluation

OMB No. 0920-0995

Attachments 3 & 4

NNPTC Abbreviated Health Professional Application for Training

(NNPTC HPAT)

Word version and screenshot

Public reporting burden of this collection of information is estimated to average 3minutes 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: PRA (0920-0995).

Today’s date ________________ Course title________________________________________________________

First name _______________________ Last name_________________________ Degree______________________

Position _______________ Work organization name __________________________________________________

Work Address _______________________City _________________ State___ County ___Zip______ Country_____

E-mail _________________________________________________________________________________________

Month and day of your birth (to create an anonymous unique code for your data). ___ ___ (MM) ___ ___(DD)

1. 3. Your principal employment setting

2. (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

3. 1. Your primary profession/

4. discipline (select ONE):

5.  Dentist

 Other dental professional

 Advanced practice nurse

 Registered nurse

 Licensed practical nurse

 Pharmacist

 Physician

 Physician Assistant

 Clergy/Faith-Based Professional

 Dietitian/Nutritionist

 Health Educator

 Mental health/behavioral health

professional

 Social worker

 Substance abuse professional

 Community health worker

 Other

(please specify)_______________

6. 2. Your primary functional role

7. (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)_______________

1. 7. What is your gender?

 Female

 Male

 Transgender (female to male)

 Transgender (male to female)

1. 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. general / family

medicine)

 Mental / behavioral health

 Oral health

 Other infectious diseases

 Other

(please specify)_______________

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

 Yes

 No

8. 8. Do you provide direct services to patients / clients who are …

9. (select ALL that apply):

ages 15-19 No Yes Not now, but expect to in the future

ages 20-24 No Yes Not now, but expect to in the future

pregnant women No Yes Not now, but expect to in the future

men who have sex with men No Yes Not now, but expect to in the future

9. Please estimate the NUMBER of clients / patients to whom you provide STD

screening, diagnosis, or treatment in an average MONTH.

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

10. Do you use the CDC STD Treatment Guidelines to guide the care of your

patients / clients?

 No, I am not aware of the Guidelines

 I am aware of the Guidelines but do not use them

 I use the Guidelines occasionally

 I use the Guidelines consistently

 I use another source to guide my STD care ( please specify )_______________

11. Are you aware of the STD Tx Guide mobile app that can be used to access the CDC STD Treatment Guidelines?

 No, I am not aware of the app

 I am aware of the app but I do not use it

 I use the app

 I use a different app for STD clinical information

Thank

Thank You!

3. 5. What is your racial background? (select ALL that apply)

 American Indian or Alaska Native

 Asian

 Black or African American

 Native Hawaiian or Pacific Islander

 White