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 # / / 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