Form 0920-0995 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 ______________________________________Phone_____________________________________________

1. 3. Your principal employment setting

2. (select ONE):

 Academic Health Center /School-based health center

 College/University

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

 Community/retail pharmacy

 Community-based service organization (CBO)

 Correctional facility

 Health department (state/local)

 HMO/managed care organization

 Hospital/Hospital-affiliated clinic

 Military Health System/ Veterans Health Admin facility

 Non-Health Setting

 Other non-profit health center

 Private practice (Solo/group)

 Rural health center

 Tribal/Indian Health Service facility

 Other (please specify)__________

 Not working

3. 1. Your primary profession/discipline (select ONE, If student, select goal):

 Advanced practice nurse / Nurse practitioner/Midwife

 Clergy/Faith-Based Professional

 Dentist

 Dietitian/Nutritionist

 Health Educator

 Licensed practical nurse

 Mental health/behavioral health professional

 Other dental professional

 Pharmacist

 Physician

 Physician Assistant

 Public health worker

 Registered nurse

 Social worker

 Substance abuse professional

 Other (please specify)___________

4. 2. Your primary functional role

5. (select ONE):

 Administrator (director, coordinator, manager, supervisor)

 Agency Board member

 Case manager

 Client/patient counselor

 Client/patient educator

 Clinical/medical assistant

 Clinician

 Disease intervention specialist / Partner services provider

 Intern /resident

 Mental/behavioral health therapist

 Nurse

 Outreach staff

 Peer support provider

 Researcher / evaluator

 Other

(please specify)_______________

1. 4. Primary programmatic focus of

your work (select up to TWO):

 HIV/AIDS

 STD

 TB

 Hepatitis

 Reproductive health/family planning/women’s health

 Recovery support/ trauma/ domestic violence

 Labor and delivery/OB/GYN

 Addiction medicine

 Adolescent and/ or pediatric health

 Cardiology/cardiac care

 Critical care

 Emergency medicine / urgent care

 Primary care (e.g. general/family medicine)

 Medical/surgical nursing

 Mental/behavioral health

 Oral health

 Other infectious diseases

 Public health

 Surgery

 Other (please specify)__________

1. 6. Please indicate your ethnic background:

 Hispanic or Latino

 Not Hispanic or Latino

2. 7. What is your gender?

 Female

 Male

 Transgender man

 Transgender woman

 Non-binary

 Other (please specify)_____

 Decline to answer

Thank

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

7. (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

3. 5. What race or races do you consider yourself to be? (select ALL that apply)

 American Indian or Alaska Native

 Asian

 Black or African American

 Native Hawaiian or Pacific Islander

 White