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Public Burden Statement:  The information on this form is collected under the authority of 42 U.S.C., Section 243 (CDC).  The requested information is used only to process your training registration and will be disclosed only upon your written request.  Continuing education credit can only be provided when all requested information is submitted.  Furnishing the information requested on this form is voluntary.


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 D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0017).


OMB Control No. 0920-0995
Exp. Date: 10/31/2016


First Name*
M
Last Name*
Degree
Title/Position
Organization:*
Address*
City*
State/Province*
Zip*
Country*
Email*
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Phone*
Fax
License Number(s)
Birth Day (MM/DD)*
1. Your primary profession/discipline*
Other
2. Your primary functional role*
Other
3. Your principal employment setting*
Other
please select up to 2 4. Primary programmatic focus of your work*
Other
5. Primary employment setting*
6. Is your employment setting a faith-based organization?*
7. Does your employment setting receive funding from any of these sources?
Ryan White Program
*
Title X / Family Planning
*
CDC
*
SAMHSA
*
Minority AIDS Initiative
*
8. Does your program predominantly serve any ethnic minority groups?*
Please select up to 2 ethnic minority groups that are a focus of your program.*
9. Does your program predominantly serve any special populations?*
Please choose up to 3 of the following populations served by your program.*
10. Are you of Hispanic, Latino/a, or Spanish origin?*
11. What is your racial background?*
Other
12. What is your sex or gender?*
Other
13. Do you provide services directly to clients or patients?*
Approximately what percentage of your client/patient population in the past year was from an ethnic minority?
*
Approximately what percentage of your client/patient population in the past year received routine HIV testing?
*
Do you provide services directly to clients/patients living with HIV?*
How many years have you been providing services directly to clients/patients living with HIV?
*
Approximately how many clients/patients living with HIV do you provide direct services to in an average month?
*
Approximately what percentage your client/patient population living with HIV during the past year was from an ethnic minority?
*
Approximately what percentage your client/patient population living with HIV during the past year was co-infected with Hepatitis C?
*
Approximately what percentage your client/patient population living with HIV during the past year was receiving antiretroviral therapy?
*
Approximately what percentage your client/patient population living with HIV during the past year consisted of women?
*
14. How did you hear about this course?
Other
Do you consent to being contacted for evaluation purposes?
15. What sex were you assigned at birth?

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