NNPTC Abbreviated Health Professional Application for Tr

National Network of Sexually Transmitted Disease Clinical Prevention Traning Centers (NNPTC)

Att 4_Revised NNPTC HPAT 2022

NNPTC Abbreviated Health Professional Applicaton for Traiing (HPAT)

OMB: 0920-0995

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OMB Control Number 0920-0995

Exp. Date 06/30/2023


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NNPTC Abbreviated Health Professional Application for Training



TODAY’S DATE

____________________________

M M D D Y Y

Your confidential 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.









FN

FN

LN

LN

M

M

D

D

CONFIDENTIAL IDENTIFIER



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).



First Name______________________ Middle Initial_________ Last Name__________________________

Degree_________________________ Title/Position_____________________________________________

Full name of your Organization__________________________________________________________________

Organization Address__________________________________________________________________________

City____________________________ State______ Zip code_________ Country _________________

Daytime Phone_______________________ E-mail _____________________


  1. Your primary profession/discipline (select ONE that best describes your profession; If student, select goal)

Academic faculty

Advanced practice nurse/Nurse Practitioner

Clinic manager/director

Dentist

Health educator

Licensed practice nurse

Laboratory specialist

Mental/behavioral health professional

Physician

Physician Assistant

Public health worker


Pharmacist

Registered nurse

Researcher

Social worker

Other (please specify) _____________


  1. Your primary functional role (select ONE that best describes your primary role)

Administrative (director, coordinator, manager, supervisor)

Clinician (Physician, Nurse)

Clinical Assistant

Case manager/Care coordinator

Client educator/Counselor

Disease Intervention Specialist


Dentist

Faculty

Laboratory specialist

Mental/behavioral health professional

Pharmacist

Public health specialist


Program manager

Resident

Researcher/evaluator

Student/Intern

Social worker

Outreach staff

Other (please specify) _____________


  1. Primary programmatic focus of your work (select ONE that best describes your area of work or clinical specialty)

HIV

STD/STI

Other Infectious disease

Reproductive health / family planning /Women’s health

Recovery support/ trauma/ domestic violence

Maternal Health

Pediatric and Adolescent health

Emergency medicine / urgent care

Primary care


Mental/behavioral health

Oral health

Public health program

Disease surveillance

Other (please specify)_____________________



  1. Your primary employment setting (select ONE)

Academic Health Center (High school, College)

Academic Institution (College/University)

Community-based organization (CBO)

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

Pharmacy

Correctional facility

Family Planning Clinic

HMO/managed care organization

Hospital/Hospital-affiliated clinic

Military Health System/ Veterans Health Admin facility

Private clinic (Solo/group)

Rural health center

State/local health department

STD Clinic

Tribal/Indian Health Service facility

Non-Health Setting

Other: (please specify)

________________

Not working



  1. If applicable, please select up to TWO minoritized racial and ethnic populations predominantly served by your program:

Not applicable

American Indian or Alaska native persons

Asian persons

Black persons or African Americans

Native Hawaiian or Pacific Islander persons

Hispanic or Latino persons

Don’t know



  1. If applicable, please select up to THREE of the following special population predominantly served by your program:

Not applicable

Ages 15 to 19

Ages 20 to 24

Homeless individuals

Incarcerated individuals/parolees

Men who have sex with men

Men who have sex with men and women

Older adults

People with disability

Pregnant people

Sex workers

Substance users

Transgender and gender diverse persons

Don’t know


  1. How do you describe your ethnicity?

Hispanic/Latino

Not Hispanic/Latino


  1. How do you describe your race? (select all that apply):

American Indian or Alaska native

Asian

Black or African American

Native Hawaiian or Pacific Islander

White


  1. Please select the gender that best describes your identity:

Female

Male

Transgender man


Transgender woman

Non-binary

Prefer not to answer


  1. Please select the sexual orientation that best describes your identity:

Lesbian

Gay

Bisexual

Transgender

Queer

Intersex

Asexual

Heterosexual

Prefer not to answer


  1. Do you provide services directly to clients or patients?

Yes No (skip logic applies)



  1. Do you provide direct services to patients / clients who are … (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 People 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


  1. Please estimate the NUMBER of clients/patients to whom you provide STI screening, diagnosis, or treatment in an average MONTH.

0 patients/Month 1-9 patients/Month 10-19 patients/Month 20-49 patients/Month 50+patients/Month



  1. Do you use the CDC STI Treatment Guidelines to guide the care of your clients/ patients?

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 ______________


  1. Are you aware of the STI 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




File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorAriyo, Oluwatosin (CDC/DDID/NCHHSTP/DSTDP)
File Modified0000-00-00
File Created2022-02-24

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