C_Participation Information Form_2021

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. Public reporting burden for this collection of information is estimated to average .06 hours per response,
including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden
estimate or any other aspect of this collection ofinformation, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14N136B,
Rockville, Maryland, 20857.

HRSA AIDS Education and Training Centers
Participant Information Form (PIF)
Instructions: This form should be completed once every 12 months by participants of the AIDS Education and Training Centers programs.
1.

Unique ID number: Enter an email address as a personal identifier:

2.

Today’s date:
M

M

D

D

Y

Y

Y

Y

3.

Your Primary Profession/Discipline (Select one)
 Dentist
 Other Dental Professional
 Nurse Practitioner/Nurse Professional (Prescriber)
 Nurse Professional (Non-Prescriber)
 Midwife
 Pharmacist
 Physician
 Physician Assistant
 Dietitian Or Nutritionist
 Mental/Behavioral Health Professional
 Substance Use Disorder 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, Physical Therapist-- Specify):
___________
 Other Public Health Professional
 Other Non-Clinical Professional (i.e., Front Desk Staff, Grant Writer -- Specify):
_____________
 Other Clinical Professional (i.e., Podiatry, Chiropractor, Alternative Medicine Specialist, Wellness Specialist, Etc. -- Specify):

4.

Your Primary Functional Role (Select one)
 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
 City, Local, State Government Employee
 Other (Specify):
_________

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
O Male
 Transgender Women
 Transgender Man
 Other Gender Identity

8.

Which of the following characteristics best describe your principal employment setting? (Select one)
 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 Use 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
 Principal Employment Setting Does Not Involve The Provision Care Or Services To Patients/Clients (Stop Here, You Are Done
With This Form.)
 I Am Not Working (Stop Here. You Are Done With This Form.)

9.

List the ZIP codes (up to three) where you provide care and services to clients:

10. Do you provide HIV prevention counseling and testing services to clients?
Yes

No

11. Do you prescribe HIV pre-exposure prophylaxis (PrEP) to clients?
Yes

No

12. Do you prescribe antiretroviral therapy (ART) to clients?
Yes

No

13. Does your principal employment setting receive Ryan White HIV/AIDS Program funding?
Yes

No

Not sure

14. Is HIV care and treatment provided by your principal employment setting?
Yes

No

15. Do you have direct interaction with clients?
Yes

No (Stop here. You are done with this form.)

16. Do you provide services directly to clients with HIV?
Yes

No (Stop here. You are done with this form.)

17. How many YEARS have you been providing services directly to clients with HIV? Round up to the nearest whole year. If less

than one year, write “01”.

18. Estimate the NUMBER of clients with HIV to whom you provided direct services in the past YEAR:

For questions 19 through 22, estimate the percentage of your clients with HIV in the past YEAR.
19. Which of the following best describes the way you provide services to clients 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 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 PERCENTAGE of your clients with HIV in the past YEAR who are racial and ethnic minorities.






None
1-24%
25-49%
50-74%
≥75%

21. Estimate the PERCENTAGE of your clients with HIV in the past YEAR with hepatitis B or hepatitis C.
 None
 1-24%
 25-49%
 50-74%
 ≥75%
22. Estimate the PERCENTAGE of your clients with HIV in the past YEAR who are receiving antiretroviral therapy.






None
1-24%
25-49%
50-74%
≥75%