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:

4.

9. Is this training part of a multi-session event?
○ Yes ○ No (Skip to question 11)

11. What session number is this training event?

M
M
D
End Date:

D

M

D

M

D

10. How many sessions are planned?

Y
Y

Y
Y

Y
Y

Y
Y

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, MAI only (Skip to question 9)
 AETC Core Funding
 CDC funding (Skip to question 9)
 CARES Act (Skip to question 9) - Remove
 EHE (Skip to question 9)
 BPHC Collaboration Funding (Skip to question 9)
 Other, (specify:__________) (Skip to question 9)
6. Of the sources of AETC programmatic funding, which of the
following were used?
 Core Training and Technical Assistance
 Practice Transformation
 Interprofessional Education (Skip to question 8)
7. Clinic ID# (For Practice Transformation Project Only) Enter
up to 30 IDs. Additional IDs can be written on the back of this form.

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

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

13. ZIP code where event was hosted (for live online events,
use state where event was hosted):

14. 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 15 through 19, check to indicate whether each
topic was covered for 15 minutes or longer during the event.
15. 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 Or Mother-To-Child Transmission
 Treatment As Prevention (e.g., U=U)
 Other Biomedical Prevention

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:
)
17. Primary care and comorbidities. Check all that apply.
 Cervical Cancer Screening, Including HPV
 Gender Affirming Care
 Hepatitis B
 Hepatitis C
 Immunization
 Influenza
 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
 Wellness Maintenance
 Other (Specify:
_____________)
18. Issues related to care of people with HIV. Check all that
apply.
o Health Literacy
o Low English Proficiency
o Motivational Interviewing
o Stigma Or Discrimination
o Other (Specify:
_______________)

19. Health care organization or systems issues. Check all that apply.
o Cultural Competence
o Cultural Humility
o Case Management
o Community Linkages
o Confidentiality / HIPPA
o Coordination Of Care
o Funding Or Resource Allocation
o Health Care Coverage (i.e., Affordable Care Act, Health
Insurance Exchanges, Managed Care)
o Legal Issues
o Organizational Infrastructure
o Organizational Needs Assessment
o Patient-Centered Medical Home
o Practice Transformation
o Quality Improvement
o Team-Based Care (i.e., Interprofessional Training)
o Telehealth
o Use Of Technology (i.e., Electronic Health Records)
o Other (Specify:____________________________)
20. 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 Latino
 Native Hawaiian Or Pacific Islander
 Other Race / Ethnicity (Specify:
_____________ )
 Women
 Gay, Lesbian, Bisexual, Transgender, Or Other Gender
 Homeless Or Unstably Housed
 Incarcerated Or Recently Released
 Immigrants
 U.S.-Mexico Border Population
 Rural Communities
 Other Special Population (Specify:
_____________)
21. Which other AETCs collaborated to organize the event?
Check all that apply.
 AETC National Coordinating Resource Center
 AETC National Clinicians’ Consultation Center
 Mid Atlantic AETC
 Midwest AETC
 Mountain West AETC
 New England AETC
 Northeast/Caribbean AETC
 Pacific AETC
 South Central AETC
 Southeast AETC
 NHC e-Learning Platform
 NHC Integration
 B-SEC Project

22. 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)
 STD Clinical Prevention Training Center (PTC)
 TB Regional Training and Medical Consultation Center
 Viral Hepatitis Education and Training Project
23. 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
 Ryan White HIV/AIDS Program-Funded Organization, Including Sub-Recipients
 Tribal College Or University
 Tribal Health Organization
 Other (Specify:________________________)
24. 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
Didactic Presentations
Interactive Presentations
Communities Of Practice
Clinical Preceptorships
Clinical Consultation
Coaching For Organizational
Capacity Building

In-Person

Distance-Based (Live)

Distance-Based
(Archived)
Not applicable
Not applicable
Not applicable
Not applicable

Start Date: / /

MM/DD/YYYY

Start Date: / /

MM/DD/YYYY

End 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.

Not applicable