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 and the expiration date is 09/30/2016. Public reporting burden for this collection of information is estimated to average .007 hours per respondent annually, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, 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 10-29, Rockville, Maryland, 20857.
HRSA AIDS Education and Training Centers
Participant Information Form (PIF)
Instructions: This form should be completed once per year by participants of the AIDS Education and Training Centers programs.
1. Unique ID number: To create your unique ID number, enter 4 letters and 4 numbers. Any 4 letters may be chosen, but a suggested format is to use the first 2 letters of your first name and first 2 letters of your last name. The numbers should be the 2-digit month and 2-digit day of your birthday. Using the suggested format, John Smith, May 29, would be JOSM0529. The same unique ID number should be used each time this form is completed.
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L |
L |
L |
L |
M |
M |
D |
D |
2. Today’s date:
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M |
M |
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D |
Y |
Y |
Y |
Y |
3. Your Primary Profession/Discipline (Select all that apply)
Dentist
Other Dental Professional
Nurse Practitioner
Nurse / Advanced Practice Nurse (non-prescriber)
Midwife
Pharmacist
Physician
Physician Assistant
Dietitian or Nutritionist
Mental/Behavioral Health Professional
Substance Abuse Professional
Social Worker or Case Manager
Community Health Worker (includes peer educator or navigator)
Clergy or Faith-based professional
Practice administrator or leader (i.e. chief executive officer, nurse administrator)
Other allied health professional (specify, i.e. medical assistant, podiatrist, physical therapist): _________________________
Other Public Health Professional
Other non-clinical professional (i.e. front desk staff, grant writer -- specify): _________________________
4. Your Primary Functional Role (Select all that apply)
Administrator
Agency Board Member
Care Provider/Clinician – can or does prescribe HIV treatment
Care Provider/Clinician – cannot or does not prescribe HIV treatment
Case Manager
HIV tester
Client/Patient Educator (includes navigator)
Clinical/Medical Assistant
Health care organization non-clinical staff (i.e. front desk)
Intern/Resident
Researcher/Evaluator
Student/Graduate Student
Teacher/Faculty
Other (specify): __________________
Please answer both questions about ethnicity (5) and race (6).
5. Are you of Hispanic or Latino/a origin?
Yes No
6. What is your racial background? Select all that apply.
American Indian / Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
7. What is your gender? Select one.
Female
Male
Transgender
8. List all the ZIP codes where you work:
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9. Principal Employment Setting name: _____________________________________________________________
10. Your Principal Employment Setting (For the clinical setting where you work most of the time, please select all the characteristics that apply to that location.)
Academic Health Center
Correctional facility
Emergency department
Federally qualified Health Center
Family Planning Clinic
HIV or Infectious Diseases Clinic
HMO/Managed Care Organization
Hospital-Based Clinic
Indian Health Services/Tribal Clinic
Long-term nursing facility
Maternal /child health clinic
Mental health clinic
STD clinic
Substance abuse treatment center
Student health clinic
Other community-based organization
Pharmacy
Military or veterans’ health facility
Other federal health facility
Private practice
State or local health department
Other primary care setting
Not working (If not working, skip to question 14.)
11. Does the principal employment setting receive Ryan White HIV/AIDS Program funding?
Yes No Not sure
12. Is HIV care and treatment provided by the principal employment setting?
Yes No
13. Do you have direct interaction with clients/patients?
Yes No (Stop here. You are done with this form.)
14. If yes, how many years?
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15. Do you provide HIV prevention counseling and testing services to clients/patients?
Yes No
16. Do you prescribe HIV pre-exposure prophylaxis (PrEP) to clients/patients?
Yes No
17. Do you provide services directly to clients/patients who are living with HIV?
Yes No (Stop here. You are done with this form.)
18. How many YEARS have you been providing services directly to people living with HIV? Round up to the nearest whole year.
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19. Which of the following best describes the way you provide services to clients/patients living with HIV:
Provide behavioral or support services, but no HIV treatment (i.e. case management, counseling, cognitive behavioral therapy, transportation, legal)
Provide clinical services to people living with HIV, but no HIV treatment (i.e. nutrition, physical therapy, psychiatry, general primary care)
Provide basic HIV care and treatment (novice)
Provide intermediate HIV care and treatment
Provide advanced HIV care and treatment
Provide expert HIV care and treatment, which includes training others and/or clinical consultation
20. Estimate the NUMBER of clients/ patients living with HIV to whom you provided direct services in the past YEAR:
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For Questions 21 through 23, estimate the PERCENTAGE of your clients/ patients living with HIV in the past YEAR who were:
21. HIV+ who are racial/ethnic minorities
None
1-24%
25-49%
50-74%
≥75%
22. HIV+ who are co-infected with hepatitis B or hepatitis C
None
1-24%
25-49%
50-74%
≥75%
23. HIV+ who are receiving antiretroviral therapy
None
1-24%
25-49%
50-74%
≥75%
| File Type | application/msword |
| File Title | HRSA AIDS Education and Training Centers |
| Author | FMalitz |
| Last Modified By | SCrooks |
| File Modified | 2016-01-22 |
| File Created | 2016-01-22 |