noen Learning group registration - word

Form Approved

OMB No. 0920-xxxx

Exp. Date: xx/xx/xxxx

Capacity Building Assistance Program: Data Management, Monitoring, and Evaluation

Attachment 3

Learning Group Registration Form

Public reporting burden of this collection of information is estimated to average 5 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: OMB-PRA (0920-New)

LEARNING GROUP REGISTRATION QUESTIONS

1. Name:

[Open text]

2. Business Street Address:

[Open text]

3. Business City, State, Zip:

[Open text]

4. Work Phone:

[Open text]

5. Work Email Address:

[Open text]

6. Job Title

[Open text]

7. Organization

[Open text]

8. What is your primary professional role?

• Administrator (e.g., director, coordinator, manager, supervisor)

• Case manager/ social worker (unlicensed)

• Clinical provider (e.g., medical doctor, registered nurse, pharmacist)

• Disease intervention specialist/ partner services provider

• HIV tester

• Mental health counselor/ behavioral health therapist/ social worker (licensed or certified)

• Navigator/ educator/ linkage specialist (e.g., community health worker, Data to Care/cluster response field staff)

• Researcher/ evaluator

• Trainer/ TA provider (specific to workforce development)

• Volunteer

9. Are you…?

• Hispanic, Latino/a, or Spanish origin

• Not Hispanic, Latino/a, or Spanish origin

10. What is your racial background? (Select all that apply)

• American Indian or Alaska Native

• Asian

• Black/ African American

• Native Hawaiian or Pacific Islander

• White

11. What sex were you assigned at birth, on your original birth certificate?

• Male

• Female

12. How do you describe your current gender identity?

• Male

• Female

• Transgender (Male to Female)

• Transgender (Female to Male)

• Other (please specify)

13. How would you describe yourself?¹

• Gay or lesbian

• Straight, that is not gay or lesbian

• Bisexual

• Something else (please specify)

• I decline to answer

14. In your role at work, do you provide services DIRECTLY to clients or patients?

• Yes

• No  Skip to Question 17

15. In your role at work, do you provide services DIRECTLY to persons with HIV?

• Yes

• No  Skip to Question 17

16. How long have you been providing DIRECT services to persons with HIV?

__ Years [Open text] and __ Months [Open text]

17. What is the focus of your work (enter “1” for your primary focus and “2” for your secondary or other focus)?

    • HIV/AIDS

    • STD

    • TB

    • Hepatitis

    • Mental/behavioral health

    • Reproductive health/ family planning

    • Recovery support/ trauma/ domestic violence

    • Labor and delivery

    • Adolescent and/or pediatric health

    • Emergency medicine/ urgent care

    • Primary care (e.g., general/family medicine)

    • Oral health

    • Other infectious diseases

    • Other (please specify)

ORGANIZATION-LEVEL QUESTIONS

18. My organization is primarily recognized as a (select one):

    • Community-based organization (CBO)/ AIDS service organization (ASO)

    • State/local health department

• Federal health agency

• Centers for Disease Control and Prevention (CDC)

• Health Resources and Services Administration (HRSA)

• Indian Health Service (IHS)

• National Institutes of Health (NIH)

• Substance Abuse and Mental Health Services Administration (SAMHSA)

• Veterans Administration (VA)

• Other federal health agency

• Health Center

• Academic health center

• Behavioral/ mental health center

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

• Rural health center

• Substance use prevention or treatment center

• College/ university

• Correctional facility

• Health maintenance organization/managed care organization

• Hospital/hospital-affiliated clinic

• Pharmacy

• Private medical practice (solo or group)

• Other (please specify)

1. What is the primary programmatic focus of your organization?

   • HIV/AIDS

   • STD

   • TB

   • Hepatitis

   • Reproductive health / family planning

   • Recovery support/ trauma/ domestic violence

   • Labor and delivery

   • Adolescent and/or pediatric health

   • Emergency medicine/ urgent care

   • Primary care (e.g., general/family medicine)

   • Mental/behavioral health

   • Oral health

   • Other infectious diseases

   • Other (please specify)

20. What is your organization’s primary setting?

    • Rural

    • Suburban/Urban

21. Estimate your organization’s percentage of overall client/patient population in the past year who were racial/ethnic minorities.

    • None

    • 1-24%

    • 25-49%

    • 50-74%

    • 75% or more

22. Does your organization predominantly serve any racial or ethnic groups?

    • Yes

    • No  Skip to Question 25

23. For those who answered yes to the previous question: Select up to TWO of the following racial or ethnic groups your organization predominantly serves:

    • American Indian or Alaskan Native

    • Asian

    • Black/ African American

    • Hispanic or Latino/a

    • Native Hawaiian or Pacific Islander

    • White

24. Does your organization predominately serve any special populations?

    • Yes

    • No  End of form

25. For those who answered yes to the previous question: Select up to THREE special populations your organization serves most often.

    • Persons with HIV

    • Adolescents

    • Homeless individuals

    • Incarcerated individuals/parolees

    • Low-income individuals

    • Men who have sex with men

    • Men who have sex with men and women

    • Older adults

    • Pregnant women

    • Recent immigrants/ refugees/migrants or seasonal workers

    • Sex workers

    • Substance users

    • Transgender individuals

    • Women

    • Other (please specify)

1 * Here is the reference for sexual orientation question. It is OMB format.

Dahlhamer, J. M., Galinsky, A. M., Joestl, S. S., & Ward, B. W. 2014. Sexual Orientation in the 2013 National Health Interview Survey: A Quality Assessment. Hyattsville, MD: NCHS, Vital Health Stat 2(169).

Available from: http://www.cdc.gov/nchs/data/series/sr_02/sr02_169.pdf.

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