Form 0920-0995 Intensive Complete Long-Term Evaluation wordversion

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

Att 7 Intensive Complete Long Term Evaluation wordversion

Intensive Complete Long-Term Evaluation

OMB: 0920-0995

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National Network of Sexually Transmitted Disease Clinical Prevention Training Centers (NNPTC): Evaluation

OMB No. 0920-0995










Attachments 7 & 8


Intensive Complete Post-Course Evaluation Instrument

Word version and screenshot


TODAY’S DATE

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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

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D

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CONFIDENTIAL IDENTIFIER







Intensive Complete Long-Term Evaluation


Public reporting burden of this collection of information is estimated to average 10 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).


A1f. I am using what I learned in this training in my work.

strongly disagree

Strongly agree


Shape1 77

NA


A2f If you have not used what you learned, please explain why not.





A3f Did you make a change in your practice or worksite setting as a result of this training?

Yes

No

Not applicable to my job or patients

I was already using these practices

Other reason (please specify)




A4f If you made a change, what change did you make?





A5f As a result of this training, did you share what you learned with any of the following? (select all that apply)

 Supervisor

 Colleagues/co-workers

 Policy makers

 Community

 Other (please specify) _____________________________


A6f Did any of these factors MAKE IT HARDER for you to apply the STD practices recommended in the training?

(select all that apply)

 lack of time with patients

 more important patient concerns

 cost/lack of reimbursement

 policies where I work

 resistance to change by supervisor or colleagues

 lack of equipment or supplies

 no opportunity to apply practices

 nothing interfered

 other, please specify ___________________________________________________








A7f Did any of these factors HELP you incorporate the STD practices recommended in the training?

(select all that apply)

 reimbursement or other financial incentive

 support of supervisor and/or colleagues

 standing orders

 reminder in chart

 convenient supplies

 posted patient instructions for obtaining specimens

 nothing specific helped

 other, please specify ___________________________________________________


UseGuidef 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 ______________



PPC1f Now, 3 months AFTER training, approximately what % of sexually active asymptomatic female

patients under age 25 are you screening annually for chlamydia?

0%

1-25%

26-50%

51-75%

76-90%

>91%


NA



PPG1f Now, 3 months AFTER training, approximately what % of sexually active asymptomatic female patients

under age 25 are you screening annually for gonorrhea?

0%

1-25%

26-50%

51-75%

76-90%

>91%


NA



PPC2f Now, 3 months AFTER training, approximately what % of pregnant patients under age 25 are you

screening for chlamydia?

0%

1-25%

26-50%

51-75%

76-90%

>91%


NA



PPG2f. Now, 3 months AFTER training, approximately what % of pregnant patients under age 25 are you

screening for gonorrhea?

0%

1-25%

26-50%

51-75%

76-90%

>91%


NA



PPG3f Now, 3 months AFTER training, approximately what % of your male patients who have sex with men

are you screening annually for gonorrhea and chlamydia?

0%

1-25%

26-50%

51-75%

76-90%

>91%


NA



PPS1f Now, 3 months AFTER training, approximately what % of your male patients who have sex with men are

you screening at least once a year for syphilis?

0%

1-25%

26-50%

51-75%

76-90%

>91%


NA



PPS3f Now, 3 months AFTER training, approximately what % of your patients recently diagnosed with

syphilis are you testing for HIV?

0%

1-25%

26-50%

51-75%

76-90%

>91%


NA



PPHPV1f Now, 3 months AFTER training with approximately what % of your non-vaccinated 11 to 26 year-old

female patients are you discussing HPV vaccination during a preventive health visit?

0%

1-25%

26-50%

51-75%

76-90%

>91%


NA


PPHPV2f Now, 3 months AFTER training, with approximately what % of your non-vaccinated 11 to 21 year-old

male patients are you discussing HPV vaccination during a preventive health visit?

0%

1-25%

26-50%

51-75%

76-90%

>91%


NA



PPHPV3f Now, 3 months AFTER training, with approximately what % of your non-vaccinated male patients

age 26 or under who have sex with men or are HIV+ are you discussing HPV vaccination during a

preventive health visit?

0%

1-25%

26-50%

51-75%

76-90%

>91%


NA




PPSH1f Now, 3 months AFTER training, for approximately what % of patients older than 15 seeing you for a

preventive health visit do you take a sexual history that asks about behaviors that would put them at risk

of getting or transmitting an STD?

0%

1-25%

26-50%

51-75%

76-90%

>91%


NA



PPSH2f Now, 3 months AFTER training, for approximately what % of patients older than 15 seeing you for a

Preventive health visit do you take a sexual history that asks whether they have had oral, vaginal, or

anal sex?

0%

1-25%

26-50%

51-75%

76-90%

>91%


NA



SGCH2f As a result of the information presented did you download the CDC STD Treatment Guidelines app?

Yes

No

NA

I was already doing this


SGCH5f As a result of the information presented did you use dual antibiotic therapy to treat uncomplicated

gonorrhea?

Yes

No

NA

I was already doing this


SGCH6f As a result of the information presented did you send a consult to the STD Clinical Consultation

Network? www.stdccn.org

Yes

No

NA

I was already doing this


SGCH7f As a result of the information presented did you recommend rescreening in 3 months following a

gonorrhea, chlamydia or trichomonas diagnosis?

Yes

No

NA

I was already doing this


SGCH8f As a result of the information presented did you use the STD Treatment Guidelines wall chart

or pocket guide?

Yes

No

NA

I was already doing this






EPTf As a result of information presented did you provide Expedited Partner Therapy (EPT) to heterosexual

partners of those diagnosed with gonorrhea and/or chlamydia?

Yes

No

Not applicable to my practice or job

Not allowed in my state/practice

My practice/worksite is in the planning stages to offer EPT

My practice/worksite was already offering EPT

EPT was not discussed


KSG1f What is the recommended treatment for a patient diagnosed with uncomplicated urethral, cervical, or

rectal gonorrhea?

Ceftriaxone 250 mg intramuscularly only

Azithromycin 2 g orally in a single dose only

Ceftriaxone 250 mg intramuscularly plus azithromycin 1 g orally in a single dose

Cefixime 400 mg orally plus doxycycline 100 mg orally BID for 7 days


KSG2f What is the recommended follow-up for a non-pregnant patient after diagnosis and treatment

of chlamydia, gonorrhea, and/or trichomonas?

  A test of cure at 2 weeks, and repeat test at 3 months

A test of cure at 2 weeks, and repeat test at 12 months

Repeat test in 3 months

Repeat test in 12 months


KSG3f What is recommended for STD screening of an HIV-negative man who reports oral sex (oral and penile

exposure) and receptive anal sex with multiple male partners?

   Pharyngeal GC, rectal GC/CT, urethral GC/CT, and syphilis every 3-6 months

Pharyngeal GC, Rectal GC/CT, urethral GC/CT and syphilis every 12-24 months

Urethral GC/CT and syphilis every 3-6 months, with pharyngeal GC and rectal GC/CT if symptoms are present

Urethral GC/CT and syphilis every 12-24 months, with pharyngeal GC and rectal GC/CT if symptoms are

Present





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