0920-0995 Abbreiviated HPAT Screenshot

ABOUT US

COURSES

E-LEARNING

RESOURCES

SIGN OUT

Form Tester
Training

Custom Forms

Questions

Form Tester

The form below is for testing purposes only.
Public reporting burden of this collection of information is estimated to average 3 minutes 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).
OMB Control No. 0920-0995
Middle Initial

First Name

Degree:

Last Name

Please write the FULL name of your organization:

Title / Position

Work Address

City

Phone

State

County

ZIP

Email

Country

Birth Day (MM/DD)

Your primary profession/discipline (select ONE):
Advanced practice nurse/nurse practitioner/midwife 
Clergy / Faith-based professional 
Dentist 
Dietitian/Nutritionist 
Health educator 
Licensed practical nurse 
Mental/Behavioral health professional 
Other dental professional 
Pharmacist 
Physician 
Physician assistant 
Public health worker 
Registered nurse 
Social worker 
Substance abuse professional 
Other (please specify) 
  Other  

Your primary functional role (select ONE):
Administrator (director, manager, coordinator, supervisor) 
Agency Board Member 
Case manager 
Client/Patient counselor 
Client/Patient educator 
Clinical/Medical assistant 
Clinician 
Disease intervention specialist / Partner services provider 
Intern/Resident/Fellow 

1/3

Mental/Behavioral health therapist 
Nurse 
Outreach staff 
Peer support provider 
Researcher/evaluator 
Student/graduate student 
Teacher/faculty 
Trainer / T.A. provider 
Other (please specify) 
  Other  

Your principal employment setting (select ONE):
Academic Health Center/School-Based Health Center 
College / University 
Community-Based 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 
Non-Health Setting 
Private Practice (Solo / Group) 
Rural Health Center 
Health Department (state/local) 
Tribal / Indian Health Service Facility 
Other (Please Specify) 
Not Working 
  Other  

What is the 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/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 Disease 
Surgery 
Public health 
Other (Please Specify) 
  Other  

What race or races do you consider yourself to be (select all that apply)?
American Indian or Alaskan Native 
Asian 
Black or African American 
Native Hawaiian or Other Pacific Islander 
White 
Are you of Hispanic, Latino/a, or Spanish origin?
Hispanic or Latino 

Not Hispanic or Latino 

Your gender:
Female 

Male 

Transgender man 

Transgender woman 

Non-binary 

Decline to answer 

Other (Please Specify) 

Other  

The National Network of STD Clinical Prevention Training Centers would like to know:

2/3

Do you provide direct services to patients/clients who are ages 15-19?
Yes 

No 

Not now, but expect to in the future 

Do you provide direct services to patients/clients who are ages 20-24?
Yes 

No 

Not now, but expect to in the future 

Do you provide direct services to patients/clients who are pregnant women?
Yes 

No 

Not now, but expect to in the future 

Do you provide direct services to patients/clients who are men who have sex with men?
Yes 

No 

Not now, but expect to in the future 

Please estimate the NUMBER of patients/clients 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. 

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 what source you use.

Are you aware of the STD Treatment 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 
Phone Number

Test Form

Cancel

© 2019 Denver National

Privacy Policy Disclaimer Contact Us

A member of the National Network of STD/HIV Prevention Training Centers. The NNPTC registration website is built and maintained by the Denver PTC, a program of
Denver Public Health, a department of Denver Health and Hospital Authority. This Website was supported by Cooperative Agreement #5U62PS003282 from the
Centers for Disease Control and Prevention. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the Centers
for Disease Control and Prevention.

3/3