Events for HIV Services

“EVOLUTION OF HEALTH – REVOLUTION OF CARE”

Tuesday, May 6, 2008
8.00—5.00 p.m.
Double Tree Hotel, San Jose
2050 Gateway Place, San Jose, CA 95110
Visit Double Tree Online

This regional conference is intended to provide evidence-based training and updates for physicians, nurses, behavioral health professionals, prevention specialists, and other healthcare providers in the counties of Santa Clara, Santa Cruz, Monterey, San Benito, and San Luis Obispo, California.

Name:

First:

Last:

Degree:

Specialty Discipline:

Physician
Physician Assistant
Nurse
Nurse Midwife
Pharmacist
Social Worker
Case Manager
Mental Health Provider
Substance Abuse Professional
Health/HIV Educator
Grants Manager
Project Manager
Non Health Discipline
Other:

Contact:

Street:

City:

State:

Zip:

Phone:
(i.e. ###-###-### ext###)
Fax:
(i.e. ###-###-####)
Email:

Where do you work?

Asian Americans for Community Involvement
Mar Monte Community Clinic
Indian Health Center of Santa Clara County
Gardner Family Health Network
MayView Community Health Center
Pacific Free Clinic
Planned Parenthood Mar Monte
Ravenswood Family Health Center
San Jose Family Foothill Community Clinic
School Health Clinics of Santa Clara Valley
Valley Medical Center
Other Clinic:
Other:

For planning purposes, please tell us which workshop sessions you plan to attend (choose one per session, view learning objectives for each session at www.chpscc.org).

Workshop Session I (10:25 – 11:55):

Breaking Barriers to Care: How Gender Identity Relates to Access
Update on Drug Interactions & Clinical Care Options
Update on HIV & Perinatal Issues: Successes & Challenges of Women's Health Advocates and Activists

Workshop Session II (1:10 – 2:40):

Rethinking Perceived Risk & Health Behaviors: What makes Latinas & African American Women Unique?
Part 1 of 2: A Shifting Crisis: When HIV is Hidden Behind the Now (co-morbidities to be addressed: Diabetes, CVD, TB)
The Power of Advocacy: Update on HIV Counseling, Testing, and Referral in the South Bay

Workshop Session III (3:00 – 4:30):

Oral sex, Drugs & Piercing: Prevention & Care of HIV among Youth
Part 2 of 2: A Shifting Crisis: When HIV is Hidden Behind the Now (co-morbidities to be addressed: Hepatitis, cancers)
HIV in Transit: from Corrections to Community Health

In which format do you want to receive conference training materials.

Hard copy program binderCD-ROM

Continuing Medical Education credit is offered by Community Health Partnership, an accredited provider. Santa Clara Valley Medical Center is approved by the California Board of Registered Nursing. This course also meets qualifications to provide credit for MFTs and LCSWs as required by the California Board of Behavioral Sciences. More information about CEUs and CMEs will be provided at www.chpscc.org and at the conference.

Do you want to receive 7 Continuing Education Units (CEUs)?

Yes

If Yes, which?
Nursing
LMFT or LCSW
Physician/Pharmacist CMEs

License Number:

No

Registration Fees:

$50 general admission
Approved volunteer
will pay my registration fees
Exhibitor name:

Payment options (payment must be received to secure your registration):

Check

Check or PO number:

Check payable to: "Community Health Partnership".
Send to: Community Health Partnership, HIV Conference, 100 North Winchester Blvd., Ste. 250, Santa Clara, CA 95050

Credit Card

First Name on card:

Last Name on card:

Type:

Number:
(numbers only)
Expire:

Security Code (last 3 or 4 digits on back of card):

Copy the address from above

Street:

City:

State:

Zip:

HRSA AIDS Education and Training Centers — Participant Information Form

1. To create your unique ID number, use the month of your birth, day of your birth, and last four digits of your SSN.

Birthday:

SSN (last 4 digits):

2. Today's date: 05/14/2008

3. Your Primary Profession/Discipline:

Dentist
Other Dental Professional
Nurse Practitioner
Other Advanced Practice Nurse
Nurse
Pharmacist
Physician
Physician Assistant
Clergy/Faith-Based Professional
Dietitian/Nutritionist
Health Educator
Mental Health Professional
Public Health Professional
Social Worker
Substance Abuse Professional
Other:

4. Your Primary Functional Role:

Administrator
Agency Board Member
Care Provider/Clinician
Case Manager
Client/Patient Educator
Intern/Resident
Researcher/Evaluator
Student/Graduate Student
Teacher/Faculty
Other:

5. Your Principal Employment Setting:

Academic Health Center
Community Health Center
Family Planning
HIV Clinic
Hospital-Based Clinic
Indian Health Services/Tribal
Infectious Disease
Maternal/Child Health
Mental Health
Rural Health
Sexually Transmitted Disease
Substance Abuse
College/University
Community-Based Organization
Correctional Facility
HMO/Managed Care Organization
Hospital/ER
Military/VA
Private Practice
State/Local Health Department
Non-Health
Other Primary Care
Not Working (skip to item 9)

6. Primary Employment Setting/Zip code:

Setting: Zip Code:

7. Is the employment setting a faith-based organization?

Yes No Don't Know

8. Does the employment setting receive Ryan White Program funding?

Yes
No
Don't Know; Employer Name:

9. Are you of Hispanic, Latino/a, or Spanish origin?

Yes No

10. Your Racial Background (select all that apply):

American Indian/Alaska Native
Asian
Black or African American
Native Hawaiian/Other Pacific Islander
White

11. Your Gender:

Female Male Transgender

12. Do you provide services directly to clients/patients?

Yes
No [Stop here. You are done with this form]

13. Do you provide services directly to HIV-infected clients/patients?

Yes
No/Don't Know [Stop here. You are done with this form]

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

(round up to the nearest whole year)

15. Estimate the NUMBER of HIV-infected clients/patients to whom you provide direct services in an average MONTH:

None [Stop here. You are done with this form]
1-9
10-19
20-49
50+

16. Estimate the PERCENTAGE of your HIV-infected clients/patients in the past YEAR who were Racial or Ethnic Minorities:

None 1-24% 25-49% 50-74% ≥75%

17. Estimate the PERCENTAGE of your HIV-infected clients/patients in the past YEAR who were on Antiretroviral Therapy:

None 1-24% 25-49% 50-74% ≥75%

18. Estimate the PERCENTAGE of your HIV-infected clients/patients in the past YEAR who were Women:

None 1-24% 25-49% 50-74% ≥75%