Event Record

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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.