Form 0920-0995 Intensive Complete Long-Term Evaluation wordversion

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

____________________________

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

Intensive Complete Long-Term Evaluation

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

strongly disagree











Strongly agree

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