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. Public reporting burden for this collection of information is estimated to average .14 hours per response, including the time for reviewing instructions, searching existing data sources, 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 14N39, 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. Were Minority AIDS Initiative funds used to support this event?
Yes No
4. Which of the following sources of funds was also used to support this event. (Select one)
Core Training and Technical Assistance (Skip to question 7)
Practice Transformation (Skip to question 5)
Interprofessional Education (Skip to question 6)
None,
MAI only (Skip to 7)
5.
Clinic ID# (for Practice Transformation Project only)
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6. Health Professional Program ID# (for Interprofessional Education Project only)
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7.
Event Date:
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M |
M |
D |
D |
Y |
Y |
Y |
Y |
8. Is this training part of a multi-session event?
Yes No (Skip to question 11)
9. How many sessions are planned?
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10.
What session number is this training event?
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11.
State where event occurred: (for live online events, use state where
event was hosted):
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12.
ZIP code where event occurred (for live online events, use state
where event was hosted):
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13. Program ID Number: The program ID number is a unique number generated by the AETC to identify the event.
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14. List the unique identifiers (email addresses) for all event participants.
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15. Check the one topic that best describes the content covered by this training.
HIV prevention
HIV testing and diagnosis
Linkage/referral to HIV care
Engagement and retention in HIV care
Antiretroviral treatment and adherence
Management of co-morbid conditions
Other, please specify: __________________
For questions 16 through 20, check to indicate whether each topic was covered for 15 minutes or longer during in the event.
16. 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
17. 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
18. 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., 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, not including opioid use
Opioid use disorder
Tobacco cessation
Tuberculosis
19. Issues related to care of people living with HIV
Cultural competence
Health literacy
Motivational interviewing
Stigma or discrimination
Low
English proficiency
20. 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)
21. Did the event address any of the following target populations? Check all that apply.
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: ________________)
22. Which other AETCs collaborate to organize the event? Check all that apply.
New England AETC
Northeast/Caribbean AETC
Mid-Atlantic AETC
Southeast AETC
Midwest AETC
South Central AETC
Mountain West AETC
Pacific AETC
AETC National Clinicians’ Consultation Center
AETC National Coordinating Resource Center
23. Which other federally-funded training centers collaborate to organize the event? Check all that apply.
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
24. Did any other organizations collaborate to organize this event? (Select all that apply)
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: ____________________________)
25. 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 |
Clinical preceptorships |
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Not applicable |
Clinical consultation |
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Not applicable |
Coaching for organizational capacity building Start date:__/___/____ MM/DD/YYYY End date:__/___._____ MM/DD/YYYY Number of Sessions During this Period: _______(#) |
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Not applicable |
26. Were continuing education credits made available to trainees?
Yes No
OMB Number: 0915-0281 Expiration date (07/31/2019).
| File Type | application/msword |
| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |