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Public Burden Statement: The information on this form is collected under the authority of 42 U.S.C., Section 243 (CDC). The requested information is used only to process your training registration and will be disclosed only upon your written request. Continuing education credit can only be provided when all requested information is submitted. Furnishing the information requested on this form is voluntary.

Public reporting burden of this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed and completing and reviewing the collection of information. 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. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN:PRA (0920-0017)

Name *
Name
Trainings You Have Taken Previously (Please check all that apply) *
Is this the first time you have attended a TTAP event? *
Pursuant to the Americans with Disabilities ACT, do you require specific aids or services? (Please check all that apply) *
HPAT Questions
4. Primary programmatic focus of your work (Please select up to TWO): *
5a. Primary Employment Setting *
6. Is your employment setting a faith-based organization? *
7. Does your employment setting receive funcding from any of these sources (select all that apply)?
7a. Ryan White Program *
7b. Title X / Family Planning *
7c. CDC *
7d. SAMHSA *
7e. Minority AIDS Initiative *
9a. Does your program predominantly serve any racial and ethnic minority groups? *
9b. If yes, select up to TWO of the following racial and ethnic groups that are a focus of your program:
10a. Does your program predominantly serve any special populations? *
10b. If yes, choose up to THREE for the following populations served by your program:
11. What is your racial background? (Select all that apply) *
12. Are you of Hispanic, Latino/a, or Spanish origin? *
13. What is your gender? *
14. Do you provide services directly to clients or patients? *
15a. Please estimate the PERCENTAGE of your OVERALL CLIENT/PATIENT population in the past YEAR who were racial-ethnic minorities:
15b. Please estimate the PERCENTAGE of your OVERALL CLIENT/PATIENT population in the past YEAR who received routine HIV Testing
16. Do you provide services directly to HIV-infected clients/patients?
18. Estimate the NUMBER of HIV-infected clients/patients to whom you provide direct services in an average MONTH.
For Questions 19 through 22, estimate the PERCENTAGE of your HIV-infected clients/patients in the past YEAR who are:
19. Racial-ethnic minorities
20. Co-infected with Hepatitis C
21. Receiving antiretroviral therapy
22. Women
24. Are you in the process of becoming certified through the New York State Peer Certification Program? *