Level II-IV Needs Assessment

Level II-IV Needs Assessment
2651294368
Florida/Caribbean AETC
Trainee to complete ALL information below
/
Anonymous Identifier: To create your unique ID number, use the
month of your birth, day of your birth, and the last 4 digits of your
social security number.
For example, May 29, 123-45-6789: ID number is 05-29-6789
/ /
birth
month
birth
day
Date:
last 4 digits of
social security #
/
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Work Zip Code:
Directions: Please use a black ink pen and fill in bubbles completely.
1. Your Profession/Discipline (Select One)
Physician
Physician Assistant
Nurse Practitioner
Nurse
Dentist
Other Dental Professional
Clinical Pharmacist
Mental Health Professional
Substance Abuse Professional
Other Health (specify)
2. Your Primary Functional Role (Select One)
Administrator/Supervisor
Care Provider/Clinician
Case Manager
Resident
Student/Graduate Student
Other (specify)
3. What is the location of your principle employment setting? (Select One)
Urban
Suburban
Rural
4. What length of program do you prefer to participate in? (Select One)
1-2 hours
2-3 hours
Half day
Full day
2-3 days
Duration is not a factor
5. What are your TOP THREE (3) preferred ways to learn?
Clinical case discussion
Lecture/presentation
Clinical mini-residency
Internet- based
Written clinical guides
E-mail/Fax/Clinical newsletter
Telephone consultation (hotline)
Other:
6. Select the HIV/AIDS related topics you are most interested in receiving further training.
Adherence issues
HIV primary care/HIV treatment guidelines
Post exposure prophylaxis
Antiretroviral treatments
Legal/ethical issues
Primary & secondary prevention
Clinical manifestations of HIV disease
Mental health/substance abuse
Psychosocial/cultural issues
Co-morbidities (Hepatitis, STD, TB)
Mother to child transmission
Quality Assurance/ CQI
Dental care
Opportunistic infection
Treatment sequencing
Diagnostic tests & disease progression
Palliative care/end of life issues
Viral load/CD4 measurements/resistance testing
Drug-drug interactions
7. Which special population issues are you most interested in receiving further training?
Women
Adolescents
Elderly
Incarcerated patients
Perinatal
Pediatric
8. Other topics of interest?
1.
2.
3.
9. What barriers do you face in obtaining training in HIV/AIDS care?
No time
No barriers
Cost
Travel restrictions
N/A: Don't need additional training
Other
10. Are you interested in clinical consultation and/or hands-on training?
On-site (at your workplace)
No
Yes
Off-site (not at your workplace)
No
Yes
11. Which modes of clinical consultation do you prefer? Select all that apply.
Telephone
Face-to-face
Group consultation/Case discussion
None
E-mail
Other
12. Have you attended any AIDS Education and Training Center (AETC) training in the past?
Yes
No
Don't Know
13. Would you like to receive current HIV/AIDS information?
Yes
No If YES, complete back of form.
OFFICE USE
ONLY
Group Name:
Code:
Subsite:
lg: 09/2002