0920-23FZ Attachment 1C-Training Evaluation Instrument - Registrat

Form Approved

OMB Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

Training Evaluation: Healthcare Outbreak Prevention and Response Curriculum for Public Health Departments

Data collection instrument: Training Registration

Data Elements

Which of the following best describes your current organizational affiliation? ​​☐​ State or territorial health department ​​☐​ Local health department   ​​☐​ Other organization [If state, territorial, or local health department] Do you work in an HAI/AR program? [Yes/No] [If state, territorial, or local health department] Please select your jurisdiction. What is your current role in the health department? How long have you been in your current role? Ethnicity (select all that apply) ☐​ Hispanic or Latino ☐​ Not Hispanic or Latino Race (select all that apply) ☐​ American Indian or Alaska Native ☐​ Asian ☐​ Black or African American ☐​ Native Hawaiian or Other Pacific Islander ☐​ White Highest level of education or training ​​☐​ Doctor of Medicine/Osteopathic Medicine (MD/DO)  ​​☐​ Doctor of Pharmacy (PharmD)  ​​☐​ Doctor of Philosophy (PhD)  ​​☐​ Doctor of Public Health (DrPH)  ​​☐​ Advanced Practice Provider (e.g., PA, NP, etc.)  ​​☐​ Registered Nurse (RN)  ​​☐​ Master of Public Health (MPH)  ​​☐​ Other Master's Degree (e.g., MBA, MPA, MSc, MSW, etc.)  ​​☐​ Bachelor's Degree (e.g., BS, BA, etc.)  ​​☐​ Associate's degree (e.g., AA, AS, ASN, etc.)  ​​☐​ High school diploma or GED  ​​☐​ Other, not listed  Please enter your work Email address

Public reporting burden of this collection of information is estimated to average 5 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 H21-8, Atlanta, Georgia 30333; ATTN: PRA XXXX-XXXX