Form 0920-0255 Questionnaire for New Organizations

Form approved

OMB No.0920-0255

Exp. date: XX/XX/XXXX

Resources and Services Database of the CDC National Prevention Information Network

Attachment 3A

NPIN Questionnaire for New Organizations

Public reporting burden of this collection of information is estimated to be 8 minutes per response, including 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, or 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 No. (0920-0255).

NPIN Questionnaire for New Organizations

Form approved OMB No.0920-0255 Exp. date: XX/XX/XXXX

Public reporting burden of this collection of information is estimated to be 8 minutes per response, including 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, or 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 No. (0920-0255).

Note: Use this script when calling an organization to be added to the NPIN Organization Database.

When calling organizations, you need to first identify yourself and the reason for your call.

Hello, my name is __________________________ and I’m calling your organization on behalf of Centers for Disease Control and Prevention’s (CDC) National Prevention Information Network. NPIN provides resources and services related to HIV/AIDS, viral hepatitis, STDs, and Tuberculosis. The mission of NPIN is to serve the information needs of State and local HIV/AIDS/Viral Hepatitis/STD/TB program personnel and other professionals. We are creating a new record for ___________________< insert organization’s primary name> and want to make sure the information we have collected is accurate. The information we collect in the NPIN database is used to update the NPIN and Get Tested Websites, and other sites like AIDS.gov. Your participation is voluntary.

Next, ask the receptionist or operator to verify the following:

• Organization Name (including any department, division, or program)

  • Be sure to confirm the primary name.

• Organization’s Corporate address or mailing Address including:

Street 1

Street 2

City
State

Zip

County

Country

• Phone Number(s)

Main Phone

Fax Number

Toll Free Number

Spanish

Other numbers

Website

• Ask if the information on the website is accurate and up to date.

• Ask for a general email address

• Ask for the email of staff contact person. It is important to get ask for an e-mail address for the staff contact(s) and inform the organization representative that going forward we will send an e-mail once a year to verify information.

• Hours of Operation

• 501(c)(3) status

• Service level

If an operator is not available and you have the option, choose the appointment line. Often times, the appointment line will provide information about hours of operation, eligibility criteria, and fees.

Next, ask to speak to the HIV program director/coordinator OR the nursing supervisor to verify the following (when possible, gather this information from the website):

• Testing Fees

• Appointment information

• Eligibility restrictions

• Services Offered (Check the services that apply)

Prevention Education
_ Behavioral Interventions
_ Condom Distribution
_ Harm Reduction
_ Hepatitis Prevention/Education
_ HIV/AIDS Prevention/Education
_ Needle Cleaning, Needle Exchange or Needle Distribution
_ Peer Education
_ Safer Sex Education
_ Speakers Bureau
_ STD Prevention/Education
_ Street Outreach
_ TB Prevention/Education
Capacity Building
_ Behavioral Interventions Training
_ Capacity Building
_ Health Professional Education
_ Public Awareness Campaigns
_ Technical Assistance
_ Training Programs
Faith Based AIDS Services
_ Faith Based AIDS Services
Financial Assistance
_ Drug Purchasing Assistance, including AIDS Drug Assistance Programs (ADAP)
_ Financial Assistance
Funding
_ Funding to Organizations
Information Resources
_ AIDS Hotlines
_ Electronic Information Resources
_ Hepatitis Hotlines
_ Materials - Print/Audiovisual
_ STD Hotlines
_ TB Hotlines
_ Treatment Information
Activism
_ Advocacy/Activism
Planning and Administration
_ Community Planning
_ Grant Management
_ Program Administration
Legal Services
_ Legal Services
Medical Services
_ Clinical Trials
_ Dental Care
_ Family Planning
_ Gynecological Care
_ Medication Adherence Education and Counseling
_ Primary Care

_ PrEP
Hepatitis Medical Services
_ Adult Hepatitis B Vaccine
_ Hepatitis A Vaccine
_ Hepatitis B Treatment
_ Hepatitis C Treatment
HIV/AIDS Medical Services
_ Alternative/Complementary Medicine
_ HIV/AIDS Medical Treatment
_ Post-Exposure Prophylaxis (PEP)
_ Pre-Exposure Prophylaxis (PrEP)
STD Medical Services
_ Human Papillomavirus Vaccine
_ STD Treatment
TB Medical Services
_ Directly Observed Therapy Short Course (DOTS)
_ TB Treatment
HIV Testing
_ Conventional HIV Testing
_ Mobile Testing Services
_ Rapid HIV Testing
Hepatitis Testing
_ Hepatitis A Testing
_ Hepatitis B Testing
_ Hepatitis C Rapid Testing
_ Hepatitis C Testing
STD Testing
_ Chlamydia Testing
_ Gonorrhea Testing
_ Herpes Testing
_ Syphilis Testing
TB Testing
_ TB Testing
Counseling
_ HIV Test Counseling
_ Partner Notification
_ Substance Abuse Treatment
Research
_ Behavioral Research
_ Research
Social Services
_ Case Management
_ Food Services
_ Housing Opportunities for Persons with AIDS/HOPWA
_ Housing Services
_ Ryan White Services
_ Transportation
Support Groups
_ Support Groups
Workplace Programs
_ Workplace Programs

• Audiences Served

General Public	Persons with HIV/AIDS
Low income	Persons with Tuberculosis
Men	Persons with Hepatitis
Women	Persons with STD
LGBT	Minorities
At risk population	Other

• Languages Spoken

Thank you for providing information about your organization.