First Name
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Last Name
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Profession
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Mailing Address
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City
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Daytime Phone
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Evening Phone
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Fax
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Affiliation
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Email Address
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Please select the dates you wish to attend the training: |
First Choice
|
Second Choice
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Describe your experience in caring for or working with
people affected by HIV/AIDS:
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Approximately how many HIV-infected clients/patients
have you interacted with in the last two years?
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Describe your knowledge level of HIV disease
(patient care, treatment, experience):
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What three things do you hope to learn from this training?
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| Indicate your interest in learning about the following topics (select all that apply): |
Assessment of newly diagnosed patients
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List any specific training site you would like to visit (refer to brochure/site descriptions/prior experience):
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