Registration Form

Registration Form

Registration Form
Denver, CO  |  7/24/2013  |  FREE

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 (0920-0995).

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

First Name
Middle Initial
Last Name
Degree:
Title / Position
Please write the FULL name of your organization:
Address
City
State
ZIP
Country
Day Phone
Alternate Phone
Email
Birth Day (MM/DD)
Your primary profession/discipline (select ONE):
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  Other  
Your primary functional role (select ONE):
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  Other  
Your principal employment setting (select ONE):
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  Other  
What is the primary programmatic focus of your work (select up to TWO):
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  Other  
Primary employment setting (physical location of your primary office)
   
ZIP Code (of your primary employment setting):
Is your employment setting a faith-based organization?
     
Does your employment setting receive Ryan White Program funding?
     
Does your employment setting receive Title X / Family Planning funding?
     
Does your employment setting receive CDC funding?
     
Does your employment setting receive SAMHSA funding?
     
Does your employment setting receive Minority AIDS Initiative funding?
     
Does your program predominantly serve any racial and ethnic minority groups?
     
Select up to TWO of the following racial and ethnic groups that are a focus of your program:
 
 
 
 
 
Does your program predominantly serve any special populations?
     
Choose up to THREE of the following populations served by your program:
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  Other  
Are you of Hispanic, Latino/a, or Spanish origin?
   
What is your racial background: (check all that apply)?
 
 
 
 
 
Your gender:
       
Do you provide services directly to clients or patients?
   
Please estimate the PERCENTAGE of your OVERALL CLIENT/PATIENT population in the past YEAR who were racial-ethnic minorities:
         
Please estimate the PERCENTAGE of your OVERALL CLIENT/PATIENT population in the past YEAR who received routine HIV testing:
         
Do you provide services directly to HIV-infected clients/patients?
   
How many YEARS have you been providing services directly to HIV-Infected clients/patients?
Estimate the NUMBER of HIV-infected clients/patients to whom you provide direct services in an average MONTH:
         
Estimate the PERCENTAGE of your HIV-infected clients/patients in the past YEAR who are RACIAL MINORITIES:
         
Estimate the PERCENTAGE of your HIV-infected clients/patients in the past YEAR who are CO-INFECTED WITH HEPATITIS C:
         
Estimate the PERCENTAGE of your HIV-infected clients/patients in the past YEAR who are RECEIVING ANTIRETROVIRAL THERAPY:
         
Estimate the PERCENTAGE of your HIV-infected clients/patients in the past YEAR who are WOMEN:
         


The Denver Prevention Training Center would like to know:

How did you hear about this course? (check all that apply)
 
 
 
 
 
 
 
 
  Other  
May we contact you for follow-up evaluation?
   
May we send you information about future courses?