B_Event Record Form_2021

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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 .14
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 of information, including suggestions for reducing this burden, to HRSA Reports Clearance
Officer, 5600 Fishers Lane, Room 14N39, Rockville, Maryland, 20857.

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