Form D Participation Information Form 218

professionPublic 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 .07 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
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 Abuse 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, podiatrist, physical therapist): _________________________
 Other Public Health Professional
 Other non-clinical professional (i.e. front desk staff, grant writer -- 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
 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
 Male
 Transgender, male-to-female
 Transgender, female-to-male
 Other gender identity

OMB Number: 0915-0281

Expiration date (07/31/2019).

8. Which of the following characteristics best describe your principal employment setting? (Select one)
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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 abuse 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
My 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 patients/clients:
__ __ __ __ __
__ __ __ __ __
__ __ __ __ __
10. Does your principal employment setting receive Ryan White HIV/AIDS Program funding?
Yes

No

Not sure

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

No

12. Do you have direct interaction with clients/patients?
Yes

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

13. Do you provide services directly to clients/patients living with HIV?
Yes

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

14. How many YEARS have you been providing services directly to clients/patients living with HIV (PLWH)? Round up to the nearest whole year. If less than one year, write “01”.

15. Do you provide HIV prevention counseling and testing services to clients/patients?
Yes

No

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

No

17. Do you prescribe antiretroviral therapy (ART) to clients/patients?
Yes

No

OMB Number: 0915-0281

Expiration date (07/31/2019).

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

19. Which of the following best describes the way you provide services to clients/patients living 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 living 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/patients living with HIV (PLWH) in the past YEAR who are racial/ethnic minorities.
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None
1-24%
25-49%
50-74%
≥75%

21. Estimate the PERCENTAGE of your clients/patients living with HIV (PLWH) in the past YEAR with hepatitis B or hepatitis C.
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None
1-24%
25-49%
50-74%
≥75%

22. Estimate the PERCENTAGE of your clients/patients living with HIV (PLWH) in the past YEAR who are receiving antiretroviral therapy.
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None
1-24%
25-49%
50-74%
≥75%

OMB Number: 0915-0281

Expiration date (07/31/2019).