Event Record Information

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. Regional Partner Number:

3. Event Dates:

State Date:

M	M	D	D	Y	Y	Y	Y

End 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 were also used to support this event. Select all that apply.

   • None,9) question to (Skip only MAI

   • AETC Base Grant Funding

   • EHE9) to question (Skip

   • BPHC Collaboration Funding9) question to (Skip

   • Other,question 9) (Skip to )__________(specify:

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

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

• Practice Transformation

• Interprofessional Education (Skip to question 8)

5. Clinic ID# (For Practice Transformation Project Only) Enter up to 30 IDs.form. this of back the on written be can IDs Additional

5. Health Professional Program ID# (For Interprofessional Education Project Only) Enter up to 5form this of back IDs. Additional IDs can be written on the

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

○ Yes ○ No (Skip to question 11)

5. How many sessions are planned?

11. What session number is this training event? (If a single session event, write 001)

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

11. ZIP code where event was hosted (for online events, use ZIP code where event was hosted):

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

• HIV Prevention

• HIV Testing And Diagnosis

• Linkage/Referral To HIV Care

• Engagement and Retention In HIV Care

• Antiretroviral Treatment And Adherence

• Management of Co-Morbid Conditions

• Rapid ART

• Other, Please Specify: ___________________________

For questions 16 through 20 check to indicate whether each topic was covered during the event.

16. HIV prevention. Check all that apply.

• Behavioral Prevention

• Harm Reduction / Safe Injection

• HIV Transmission Risk Assessment

• Postexposure Prophylaxis (PEP, Occupational and Non-occupational)

• Preexposure Prophylaxis (PrEP)

• Prevention of Perinatal Transmission

• Treatment as Prevention (e.g., U=U)

• Other Biomedical Prevention

• Sexual Health History Taking

16. HIV background and management. Check all that apply.

• Acute HIV

• Adult and Adolescent Antiretroviral Treatment

• Aging and HIV

• Antiretroviral Treatment Adherence, Including Viral Load Suppression

• Basic Science

• Clinical Manifestations of HIV Disease

• HIV Diagnosis (i.e.,HIV Testing)

• HIV Epidemiology

• HIV Monitoring Lab Tests (i.e.,CD4 and Viral Load)

• HIV Resistance Testing And Interpretation

• Linkage to Care

• Pediatric HIV Management

• Retention and/or Re-Engagement In Care

• Other) (Specify:

16. Primary care and comorbidities. apply. that Check all

• Cervical Cancer Screening, Including HPV

• Hepatitis B

• Hepatitis C

• Immunization

• Influenza

• Coronavirus disease 2019 (COVID-19)

• Malignancies

• Medication-Assisted Therapy for Substance Use Disorders (i.e.,Buprenorphine, Methadone, and/or Naltrexone)

• Mental Health Disorders

• Non-Infection Comorbidities of HIV or Viral Hepatitis (i.e.,Cardiovascular, Neurologic, Renal Disease)

• Nutrition

• Opportunistic Infections

• Oral Health

• Osteoporosis

• Pain Management

• Palliative Care

• Primary Care Screenings

• Reproductive Health, Including Preconception Planning

• Sexually Transmitted Infections

• Substance Use Disorders, Not Including Opioid Use

• Opioid Use Disorder

• Tobacco Cessation

• Tuberculosis

• Health or Wellness Maintenance

• Other (Specify: _____________)

16. Issues related to care of people with HIV. Check allapply. that

• Health Literacy

• Low English Proficiency

• Stigma or Discrimination

• Stress management/Resiliency

• Other _______________(Specify:

16. Health care organization or systems issues. Check all that apply.

• CulturalCompetence / Cultural Humility

• Case Management

• Community Linkage

• Confidentiality / HIPAA

• Care Coordination

• Funding Or Resource Allocation

• Gender Affirming Care

• Health Care Coverage (i.e., Affordable Care Act, Health Insurance Exchanges, Managed Care)

• Legal Issues

• MotivationalInterviewing

• Organizational Infrastructure

• Organizational Needs Assessment

• Patient-Centered Medical Home

• Practice Transformation

• Quality Improvement

• Team-Based Care (i.e., Interprofessional Training)

• Telehealth

• Trauma Informed Care

• Use of Technology (i.e., Electronic Health Records)

• Other (Specify:____________________________)

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

• Children (Ages 0 To 12)

• Adolescents (Ages 13 To 17)

• Young Adults (Ages 18 To 24)

• Older Adults (Ages 50 And Over)

• American Indian or Alaska Native

• Asian

• Black or African American

• Hispanic or LatinX

• Native Hawaiian Or Pacific Islander

• Other Race / Ethnicity (Specify: _____________ )

• Women

• Gay, Lesbian, Bisexual

• Transgender/Non-Binary/Other Gender

• People Experiencing H omelessness

• People with Justice System I nvolvement

• Immigrants or Refugees

• U.S.-Mexico Border Population

• Rural Communities

• People Who Inject Drugs (PWID)

• Veterans

• Other Special Population (Specify: _____________)

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

• Mid-Atlantic AETC

• Midwest AETC

• Mountain West AETC

• New England AETC

• Northeast/Caribbean AETC

• Pacific AETC

• South Central AETC

• Southeast AETC

• AETCCenter Resource Coordinating National

• AETCCenter Consultation Clinician National

• National HIV Curriculum (NHC)

• Programs

• Building the HIV Wagement in Communities of Color (orkforce and Strengthening EngB-SEC) Project

16. Which other federally-funded training centers collaborate to organize the event? Check all that apply.

• Addiction Technology Transfer Center (ATTC)

• Area Health Education Center (AHEC)

• Capacity Building Assistance (CBA) Provider

• Family Planning National Training Center

• Mental Health Technology Transfer Centers (MHTTC)

• Public Health Training Center (PHTC)

• National Network of Prevention Training Centers of CDC (NNPTC)

• TB Regional Training and Medical Consultation Center

• Viral Hepatitis Education and Training Project

16. Did any other organizations collaborate to organize this event? Check all that apply.

• AIDS Services Organization

• Other Community-Based Organization

• Community Health Center, or Federally Qualified Health Center (FQHC) Funded by HRSA

• Correctional Institution

• Faith-Based Organization

• Health Professions School

• Historically Black College or University

• Hispanic-Serving Institution

• Hospital or Hospital-Based Clinic

• Local/State Health Department

• Ryan White HIV/AIDS Program-Funded Organization, Including Sub-Recipients

• Tribal College or University

• Tribal Health Organization

• Federal Partners (OASH, SAMHSA, etc).

• Research Networks (CFAR, ACTG, etc.)

• Academic Institution

• Other (Specify:________________________)

16. 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
Communities of Practice			Not applicable
Clinical Preceptorships			Not applicable
Clinical Consultation			Not applicable
Technical Assistance			Notapplicable
Coaching for Practice Transformation			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:

26. Were continuing education credits made available to trainees?

○ Yes ○ No

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