Form C FINAL Event Record Form Change memo version

Public Burden Statement: 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. The OMB control number for this project is 0915-0281. Public reporting burden for this collection of information is estimated to average .14 hours per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14N39, Rockville, Maryland, 20857.

HRSA AIDS Education and Training Centers EVENT RECORD

Instructions: This form should be completed by the program office or trainer that sponsored the training event. Name of Event:

1. AETC Number:

2. Local Partner number:

3. Event Date:

M	M	D	D	Y	Y	Y	Y

4. Were any Minority AIDS Initiative funds used to support this event?

   • Yes No

5. Which of the following sources of funds was also used to support this event. (Select one)

   • MAI

   • AETC

   • CDC funding

   • CARES Act

   • EHE

   • Other, :____________________)specify(

6. Of the sources of AETC programmatic funding, which of the following were used?

   • Core Training and Technical Assistance (Skip to question 9)

   • Practice Transformation (Skip to question 7)

   • Interprofessional Education (Skip to question 8)

   • None, MAI only (Skip to 9)

7. Clinic ID# (for Practice Transformation Project only)

8. Health Professional Program ID# (for Interprofessional Education Project only)

9. Is this training part of a multi-session event?

   • Yes No (Skip to question 11)

10. How many sessions are planned?

11. What session number is this training event?

12. State where event occurred: (for live online events, use state where event was hosted):

13. ZIP code where event was hosted (for live online events, use state where event was hosted):

15. Select the topics that best describe the content covered by this training. Check all that apply.

    1. HIV prevention

    2. HIV testing and diagnosis

    3. Linkage/referral to HIV care

    4. Engagement and retention in HIV care

    5. Antiretroviral treatment and adherence

    6. Management of co-morbid conditions

    7. Other, please specify

For questions 16 through 20, check to indicate whether each topic was covered for 15 minutes or longer during in the event.

15. HIV prevention

    1. Behavioral prevention

    2. Harm reduction / safe injection

    3. HIV transmission risk assessment

    4. Postexposure prophylaxis (PEP, occupational and nonoccupational)

    5. Preexposure prophylaxis (PrEP)

    6. Prevention of perinatal or mother-to-child transmission

    7. U=U/treatment as prevention

    8. Other biomedical prevention

15. HIV background and management

    1. Acute HIV

    2. Adult and adolescent antiretroviral treatment

    3. Aging and HIV

    4. Antiretroviral treatment adherence, including viral load suppression

    5. Basic Science

    6. Clinical manifestations of HIV disease

    7. HIV diagnosis (i.e. HIV testing)

    8. HIV epidemiology

    9. HIV monitoring lab tests (i.e. CD4 and viral load)

    10. HIV resistance testing and interpretation

    11. Linkage to care

    12. Pediatric HIV management

    13. Retention and/or re-engagement in care

    14. Other (specify: )

15. Primary Care and Comorbidities

    1. Cervical cancer screening, including HPV

    2. Hepatitis B

    3. Hepatitis C

    4. Immunization

    5. Influenza

    6. Malignancies

    7. Medication-assisted therapy for substance use disorders (i.e., buprenorphine, methadone, and/or naltrexone)

    8. Mental health disorders

    9. Non-infection comorbidities of HIV or viral hepatitis (i.e. cardiovascular, neurologic, renal disease)

    10. Nutrition

    11. Opportunistic infections

    12. Oral health

    13. Osteoporosis

    14. Pain management

    15. Palliative care

    16. Primary care screenings

    17. Reproductive health, including preconception planning

    18. Sexually transmitted infections

    19. Substance use disorders, not including opioid use

    20. Opioid use disorder

    21. Tobacco cessation

    22. Tuberculosis

    23. Other (specify: )

15. Issues related to care of people living with HIV

    1. Cultural competence

    2. Health literacy

    3. Low English proficiency

    4. Motivational interviewing

    5. Stigma or discrimination

15. Health care organization or systems issues

    1. Billing for services and payment models

    2. Case management

    3. Community linkages

    4. Confidentiality / HIPAA

    5. Coordination of care

    6. Funding or resource allocation

    7. Health insurance coverage (i.e. Affordable Care Act, health insurance exchanges, managed care)

    8. Legal issues

    9. Organizational infrastructure

    10. Organizational needs assessment

    11. Patient-centered medical home

    12. Practice Transformation

    13. Quality Improvement

    14. Team-based care (i.e. interprofessional training)

    15. Telehealth

    16. Use of technology (i.e. electronic health records)

16. Did the event address any of the following target populations? Check all that apply.

    1. Children (ages 0 to 12)

    2. Adolescents (ages 13 to 17)

    3. Young adults (ages 18 to 24)

    4. Older adults (ages 50 and over)

    5. American Indian or Alaska Native

    6. Asian

    7. Black or African American

    8. Hispanic or Latino

    9. Native Hawaiian or Pacific Islander

    10. Other race / ethnicity (specify: )

    11. Women

    12. Gay, lesbian, bisexual, transgender, or other gender

    13. Homeless or unstably housed

    14. Incarcerated or recently released

    15. Immigrants

    16. U.S.-Mexico border population

    17. Rural populations

    18. Other special population (specify: )

15. Which other AETCs collaborated to organize the event? Check all that apply.

    1. AETC National Coordinating Resource Center

    2. AETC National Clinicians’ Consultation Center

    3. Mid Atlantic AETC

    4. Midwest AETC

    5. Mountain West AETC

    6. New England AETC

    7. Northeast/Caribbean AETC

    8. Pacific AETC

    9. South Central AETC

    10. Southeast AETC

15. Which other federally-funded training centers collaborate to organizethe event? Check all that apply.

    1. Addiction Technology Transfer Center (ATTC)

    2. Area Health Education Center (AHEC)

    3. Capacity Building Assistance (CBA) Provider

    4. Family Planning National Training Center

    5. Mental Health Technology Transfer Centers (MHTTC)

    6. Public Health Training Center (PHTC)

    7. STD Clinical Prevention Training Center (PTC)

    8. TB Regional Training and Medical Consultation Center

    9. Viral Hepatitis Education and Training Project

15. Did any other organizations collaborate to organize this event? (Select all that apply)

    1. AIDS services organization

    2. Other community-based organization

    3. Community health center, or Federally Qualified Health Center (FQHC) funded by HRSA

    4. Correctional institution

    5. Faith-based organization

    6. Health professions school

    7. Historically Black College or University

    8. Hispanic-Serving Institution

    9. Hospital or hospital-based clinic

    10. Ryan White HIV/AIDS Program-funded organization, including subrecipients

    11. Tribal College or University

    12. Tribal health organization

    13. Other (specify: _)

15. Number of hours for each type of training or technical assistance modality for the event. Enter hours rounded to the nearest ¼ hour in each cell (.25 = ¼, .50 =

½ hour, .75 = ¾ hour). Do not enter data into cells that contain “not applicable.”

Training and TA Modality	In-person	Distance-based (live)	Distance-based (archived)
Didactic presentations
Interactive presentations			Not applicable
Communities of practice			Not applicable
Clinical preceptorships			Not applicable
Clinical consultation			Not applicable
Coaching for organizational capacity building			Not applicable
	Start date: / / MM/DD/YYYY End date: / / MM/DD/YYYY	Start date: / / MM/DD/YYYY End date: / / MM/DD/YYYY
Number of Sessions During this Period:

15. Were continuing education credits made available to trainees?

• Yes No

15. Program ID Number: The program ID number is a unique number generated by the AETC to identify the event.

OMB Number: 0915-0281

Expiration date (06/30/2022).