Info Training Request Form First Name Last Name Name of your agency/clinic Street address of your agency/clinic City State Zip Code Your role/title at your agency Telephone Email address Fax Pager Profession of trainee(s) (select all that apply) Physician Advanced practice nurse Nurse Physician assistant Pharmacist Oral health professional Other If Other, please explain: Estimated number of trainees Select the clinical topics on which you'd like to receive training: Clinical manifestations of HIV HIV-focused history-taking and physical exam skills for clinicians Antiretroviral therapy: initiating, adjusting, and managing side effects Lab monitoring in HIV care Preventing and managing opportunistic infections HIV/hepatitis coinfection Tuberculosis/HIV coinfection Sexually-transmitted disease coinfection Mental illness/HIV comorbidity, assessment and care Substance abuse/HIV comorbidity, assessment and care Pain management Palliative care/end of life care Oral health issues in HIV Acute/primary HIV infection Preconception care, pregnancy, and HIV Other If Other, please explain: Select the care-related topics on which you'd like to receive training: Medication adherence support Medical case management Legal issues in HIV care Prevention/risk reduction for HIV patients Prevention/risk reduction for uninfected patients Disruptive/choatic patients Taking a sexual history Routine HIV testing services Post-exposure prophylaxis Culturally/linguistically competent HIV care Making the most of case manager support Clinic staff teambuilding ADAP issues (AIDS Drug Assistance Program) Other If Other, please explain: Select the special populations on which you'd like to receive training: Transgendered persons Women in their reproductive years Adolescents Rural persons African-American persons Lation(a)/Spanish-speaking persons Persons over age 50 Substance users Persons with mental illness Incarcerated/parolees/probationers Gay/lesbian persons Recent immigrants Migrant workers Other If Other, please explain: From this list of ways to receive training, select 1: Onsite group training: 1-3 hours Onsite group training: 4 or more hours Networked training/webconference Clinicial one-on-one training (Preceptorship): Full day or more Other If Other, please explain: Please describe when you would like the training to occur (a preferred day of the week, prior to a certain date, etc.). What type of Ryan White funding does your agency receive? (Check all that apply.) Part A Part B Part C Part D Part F N/A (Receives no Ryan White funding) Don't Know NOTE: The next 4 questions are for clinical providers only. All others are done with this form. Please scroll to the end and click Submit. In the past year, have you sought expert advice regarding treatment for an HIV-infected patient in your care? Yes No If yes, how did you communicate with the expert? (Check all that apply.) Telephone consultation with a specialist Telephone hotline/warmline Face to face Email Telemedicine or case conference Other If Other, please explain: Have you encountered any barriers in accessing expert consultation on HIV treatment? Yes No If yes, what barrier did you encounter? (Check all that apply.) My call/email was not returned in a timely manner Did not know whom to call/email Did not know telephone number/email address for an expert Other If Other, please explain: Application submission and next steps Click the button below to submit this application. Once we've had a chance to review your information, NCATEC's Program Coordinator will contact you to plan your training.