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
Name:
[Open text]
Business Street Address:
[Open text]
Business City, State, Zip:
[Open text]
Work Phone:
[Open text]
Work Email Address:
[Open text]
Job Title
[Open text]
Organization
[Open text]
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
Are you…?
Hispanic, Latino/a, or Spanish origin
Not Hispanic, Latino/a, or Spanish origin
What is your racial background? (Select all that apply)
American Indian or Alaska Native
Asian
Black/ African American
Native Hawaiian or Pacific Islander
White
What sex were you assigned at birth, on your original birth certificate?
Male
Female
How do you describe your current gender identity?
Male
Female
Transgender (Male to Female)
Transgender (Female to Male)
Other (please specify)
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
In your role at work, do you provide services DIRECTLY to clients or patients?
Yes
No Skip to Question 17
In your role at work, do you provide services DIRECTLY to persons with HIV?
Yes
No Skip to Question 17
How long have you been providing DIRECT services to persons with HIV?
__ Years [Open text] and __ Months [Open text]
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
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)
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)
What is your organization’s primary setting?
Rural
Suburban/Urban
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
Does your organization predominantly serve any racial or ethnic groups?
Yes
No Skip to Question 25
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
Does your organization predominately serve any special populations?
Yes
No End of form
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.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Dr. Sherese Garrett;Sherese Garrett |
| File Modified | 0000-00-00 |
| File Created | 2021-01-13 |