Form 0920-0255 Questionnarier for Annual Updates Telephone

Form Approved

OMB No. 0920-0255

Exp. date: XX/XX/XXXX

Resources and Services Database of the CDC National Prevention Information Network

Attachment 3B

NPIN Questionnaire for Annual Updates

Public reporting burden of this collection of information is estimated to be 6 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 Annual Updates

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

Public reporting burden of this collection of information is estimated to be 6 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 verify the information already in the 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 updating the NPIN Organizations Database and want to make sure the information we have for ___________________< insert organization’s primary name> 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:

• Name

  • Be sure to confirm the primary name.

• Address

• Phone Number(s)

• Website

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

  • Get general e-mail address (es) from website.

• 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:

• Testing Fees

• Appointment information

• Eligibility restrictions

• Services Offered. Read the services listed on the existing record. Mark any changes below.

Prevention Education		HIV Testing
Financial Assistance			Conventional HIV test
	ADAP		Mobile testing
Funding			Rapid HIV Test
	Funding to Orgs	Hepatitis Testing
Legal Services			Hepatitis A testing
			Hepatitis B testing
Medical Services			Hepatitis C rapid test
	Clinical Trials		Hepatitis C testing
	Family Planning	STD Testing
	Primary Care		Chlamydia
Hepatitis Medical Services	Adult Hepatitis B Vaccine		Gonorrhea
	Hepatitis A Vaccine		Herpes
	Hepatitis B treatment		Syphilis
	Hepatitis C treatment	TB testing
HIV/AIDS Medical			TB testing
	Alternative Medicine	Counseling	HIV test Counseling
	HIV/AIDS Medical Tx		Partner notification
	PEP	Research
	PrEP	Social Services
STD Medical Services	HP Vaccine		Case Management
	STD Treatment		Ryan White

• Audiences Served. Read the audience selected on the existing record. Mark any changes below.

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

Finally, thank the organization for updating the information.

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