NNPTC Abbreviated Health Professional Application for Tr

OMB Control Number 0920-0995

Exp. Date 06/30/2023

NNPTC Abbreviated Health Professional Application for Training

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

Public reporting burden of this collection of information is estimated to average 3 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).

First Name______________________ Middle Initial_________ Last Name__________________________

Degree_________________________ Title/Position_____________________________________________

Full name of your organization__________________________________________________________________

Organization Address__________________________________________________________________________

City_____________________ State______ Zip code_________ County _____________ Country_________

Daytime Phone_______________________ E-mail _____________________

1. Your primary profession/discipline (select ONE that best describes your profession; If student, select goal)

 Academic faculty

 Advanced practice nurse/Nurse Practitioner

 Clinic manager/director

 Dentist

 Health educator

 Licensed practice nurse

 Laboratory specialist

 Mental/behavioral health professional

 Physician

 Physician Assistant

 Public health worker

 Pharmacist

 Registered nurse

 Researcher

 Social worker

Other (please specify) _____________

2. Your primary functional role (select ONE that best describes your primary role)

 Administrative (director, coordinator, manager, supervisor)

 Clinician (Physician, Nurse)

 Clinical Assistant

 Case manager/Care coordinator

 Client educator/Counselor

 Disease Intervention Specialist

 Dentist

 Faculty

 Laboratory specialist

 Mental/behavioral health professional

 Pharmacist

 Public health specialist

 Program manager

 Resident

 Researcher/evaluator

 Student/Intern

 Social worker

Outreach staff

Other (please specify) _____________

3. Primary programmatic focus of your work (select ONE that best describes your area of work or clinical specialty)

 HIV

 STD/STI

 Other Infectious disease

 Reproductive health / family planning /Women’s health

 Recovery support/ trauma/ domestic violence

 Maternal Health

 Pediatric and Adolescent health

 Emergency medicine / urgent care

 Primary care

 Mental/behavioral health

 Oral health

 Public health program

 Disease surveillance

 Other (please specify)___________________

4. Your primary employment setting (select ONE)

 Academic Health Center (High school, College)

 Academic Institution (College/University)

 Community-based organization (CBO)

 Community health center (e.g., Federally Qualified Health Center)

 Pharmacy

 Correctional facility

 Family Planning Clinic

 HMO/managed care organization

 Hospital/Hospital-affiliated clinic

 Military Health System/ Veterans Health Admin facility

 Private clinic (Solo/group)

 Rural health center

 State/local health department

 STD Clinic

 Tribal/Indian Health Service facility

 Non-Health Setting

 Other: (please specify)

________________

 Not working

5. If applicable, please select up to TWO minoritized racial and ethnic populations predominantly served by your program:

 Not applicable

 American Indian or Alaska native persons

 Asian persons

 Black persons or African Americans

 Native Hawaiian or Pacific Islander persons

 Hispanic or Latino persons

 Don’t know

6. If applicable, please select up to THREE of the following special population predominantly served by your program:

 Not applicable

 Ages 15 to 19

 Ages 20 to 24

 Homeless individuals

 Incarcerated individuals/parolees

 Men who have sex with men

 Men who have sex with men and women

 Older adults

 People with disability

 Pregnant people

 Sex workers

 Substance users

 Transgender and gender diverse persons

 Don’t know

7. How do you describe your ethnicity?

 Hispanic/Latino

 Not Hispanic/Latino

 Prefer not to answer

8. How do you describe your race? (select all that apply):

 American Indian or Alaska native

 Asian

 Black or African American

 Native Hawaiian or Pacific Islander

 White

 Other

 Prefer not to answer

9. Please select the gender that best describes your identity:

 Female

 Male

 Transgender man

 Transgender woman

 Non-binary

 Other

 Prefer not to answer

10. Please select the sexual orientation that best describes your identity:

 Lesbian

 Gay

 Bisexual

 Queer

 Asexual

 Heterosexual

 Intersex

 Prefer not to answer

11. Do you provide services directly to clients or patients?

 Yes  No (skip logic applies)

12. Do you provide direct services to patients / clients who are … (select ALL that apply):

Ages 15-19 No Yes Not now, but expect to in the future

Ages 20-24 No Yes Not now, but expect to in the future

Pregnant People No Yes Not now, but expect to in the future

Men who have sex with men No Yes Not now, but expect to in the future

13. Please estimate the NUMBER of clients/patients to whom you provide STI screening, diagnosis, or treatment in an average MONTH.

 0 patients/Month  1-9 patients/Month  10-19 patients/Month  20-49 patients/Month  50+patients/Month

14. Do you use the CDC STI Treatment Guidelines to guide the care of your clients/ patients?

 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 ______________

15. Are you aware of the STI Treatment Guide mobile app that can be used to access the CDC STD Treatment Guidelines?

 No, I am not aware of the app

 I am aware of the app but I do not use it

 I use the app

 I use a different app for STD clinical information