The following calendar offers current classes and mammography events.

* Required

Title DR MISS MR MRS MS

First Name *

Last Name *

Email Address *

Work Phone Number *

Check Number *

UID *

Your Primary Profession/Discipline (Select One) -- Please select -- Dentist Other Dental Professional Advanced Practic Nurse Nurse Pharmacist Physician Physician Assistant Clergy/Faith-Based Professional Dietitian/Nutrionist Health Educator Mental/Behavioral Health Professional Social Worker Substance Abuse Professional Community Health Worker Other non-clinical professional (specify)

Profession Other

Your Primary Functional Role (Select One) -- Please select -- Administrator Agency Board Member Care Provider/Clinician Case Manager Client/Patient Educator Clinical/Medical Assistant Intern/Resident Research Evaluator Student/Graduate Student Teacher Faculty Other (specify)

Your Primary Employment Setting (Select One) -- Please select -- Academic Health Center Community Health Center Family Planning Clinic HIV Clinic HMO/Managed Cared Organization Hospital-Based Clinic Hospital/ER Indian Health Services/Tribal Clinic Infectious Disease Clinic Long-Term Nursing Facility Maternal/Child Health Clinic Mental/Behavioral Health Clinic Rural Health Clinic Sexually Transmitted Disease Clinic Substance Abuse Treatment Center College/University Community-Based Organization Community/retail pharmacy Correctional Facility Military/VA Private Practice State/Local Health Department Non-Health Other Primary Care Not Working

Functional Role Other

Primary Employment Setting Rural Suburban/Urban

Zip Code *

Is the employment setting a faith-based organization? Yes No Don't Know

Does the Employment setting receive Ryan White Program funding? Yes No Don't Know

If 8a=Don't Know, please write the full name of your agency

What is your racial background? (Select all that apply) American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White

What is your gender? Female Male Transgender

Please estimate the PERCENTAGE of your OVERALL CLIENT/PATIENT population in the past YEAR who were racial-ethnic minorities: None/yr. 1-24%/yr 25-49%/yr 50-74%/yr ≥75%/yr

Do you provide services directly to HIV-infected clients/patients? Yes Don't Know(Stop here. You are done with this form)

How many YEARS have you been providing services directly to HIV-infected clients/patients?

Estimate the NUMBER of HIV-infected clients/patient to whom you provide direct services in an average MONTH. None/mo. 1-9/mo. 10-19/mo. 20-49/mo. 50+/mo.

HIV+ who are racial-ethnic minorities None/yr. 1-24%/yr 25-49%/yr 50-74%/yr ≥75%/yr

HIV+ who are co-infected with Hepatitis C None/yr. 1-24%/yr 25-49%/yr 50-74%/yr ≥75%/yr

HIV+ who are receiving antiretroviral therapy None/yr. 1-24%/yr 25-49%/yr 50-74%/yr ≥75%/yr

HIV+ who are women None/yr. 1-24%/yr 25-49%/yr 50-74%/yr ≥75%/yr

Degree *

Specialty Discipline * -- Please select -- Physician Physician Assistant Nurse Advanced Practice Nurse Pharmacist Social Worker Mental/Behavioral Health Provider Substance Abuse Professional Health/HIV Educator Public Health Professional Dietitian/Nutrionist Dentist Other Dental Professional Other

Other Discipline

Where do you work? -- Please select -- Asian Americans for Community Involvement Gardner Family Health Network Indian Health Centers of Santa Clara County Mar Monte Community Clinic MayView Community Health Center North East Medical Services Pacific Free Clinic Planned Parenthood Mar Monte Ravenswood Family Health Center RotaCare Bay Area Foothill Health Center School Health Clinics of Santa Clara Valley Santa Clara Medical Center Other

Other work

Workshop I TR: A Dramatic Approach to HIV Mental Health AC: Legal Aspects of HIV Updates Privacy and Ethics

Workshop II TR: Women & HIV AC: Incorporating Prevention into the Medical Care

Workshop III TR: Drug Interactions & HIV AC:HIV in the Latino Population

If yes, which? Nursing LCSW or LMFT

License

Are youof Hispanic, Latino/a, or Spanish origin? Yes No

Do you provide services directly to clients/patients? Yes No

Do you want to receive 7 Continuing Education Units (CEUs)? Yes No