Form 0920- National Learning Community for HIV CBO Leadership Regis

Form Approved

OMB No. 0920-xxxx

Exp. Date: xx/xx/xxxx

National Learning Community for HIV CBO Leadership Evaluation

Attachment 4

National Learning Community for HIV CBO Leadership Registration Form

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: OMB-PRA (0920-New)

Your unique ID number is:
the first two letters of your first name,
the first two letters of your last name,
the month of your birth,
and the day of your birth.
For example: John Smith, May 29
would be JOSM-0529. UNIQUE IDENTIFIER

				--
FN	FN	LN	LN	--	M	M	D	D

1. Has your supervisor approved your participation in the National Learning Community for HIV CBO Leadership?

• Yes

• No  [we strongly recommend that you get approval before continuing]

Your contact info

2. Business street address: ____________________

3. Business city, state, and zip: ________________________

4. Work phone: ______________________

5. Job title: _______________________________

Tell us about yourself

6. Are you…?

• Hispanic or Latino

• Not Hispanic or Latino

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

• American Indian or Alaskan Native

• Asian

• Black or African American

• Native Hawaiian or Other Pacific Islander

• White

8. Which of the following best represents how you think of yourself?

• [Gay / lesbian or gay]

• Straight, that is not [gay / lesbian or gay]

• Bisexual

• Something else

• I don’t know the answer

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

• Male

• Female

• Refused

• I don’t know

10. Do you currently describe yourself as male, female, or transgender?

• Male

• Female

• Transgender

• None of these

Tell us about your organization

11. What is your organization’s primary setting?

• Rural

• Suburban/Urban

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

• 0

• 1-24%

• 25-49%

• 50-74%

• 75% or more

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

• Yes [If yes  Q14]

• No [If no  Q15]

14. 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
  
  

15. Has your organization received training or technical assistance services from CDC’s Capacity Building Assistance Provider Network in the past 12 months?

• Yes

• No

• I am not sure

Tell us about your work experience

16. How long have you been in a management position in HIV services?

• Under a year

• 1-2 years

• 3-5 years

• > 5 years

17. How long have you been in your current position?

• Under a year

• 1-2 years

• 3-5 years

• > 5 years

18. How many people do you currently supervise?

• 0

• 1-5

• 6-10

• > 10

19. What is the reason(s) you wish to participate in the National Learning Community for HIV CBO Leadership? (check all that apply)

• My supervisor recommended I enroll

• Our organization’s CDC Prevention Program Branch project officer recommended it to me / our organization

• I am interested in professional growth

• To increase my chances of promotion

• I want to take advantage of a free training opportunity

Tell us about your learning priorities

20. Which managerial area would be your highest priority to work on first?

• Managing People (e.g., recruitment, hiring, staff capacity, staff retention, supervision, burnout)

• Managing Programs (e.g., collaborations, program deliverables, reaching target populations)

• Managing Organizations (e.g., working with stakeholders, budgets, organizational culture, boards, fundraising)

OPTIONAL

21. Please describe how you would like to grow in your management skills in your priority area. (500 words or less)