JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Fall 2019 Hepatitis C Provider Training-Registration Form
Please complete the entire form before 10/1
Sign in to Google
to save your progress.
Learn more
First Name
Your answer
Last Name
Your answer
E-mail Address
Your answer
Phone Number
Your answer
How did you hear about this program?
Grand Rounds Session
Word-of-mouth
Supervisor
E-mail
Have you taken part in any other hepatitis C training courses in the past 12 months?
Yes
No
Clear selection
If yes, when and where
Your answer
Credentials (please select all that apply)
MD/DO
PA
NP
RN
PharmD
Other:
Which of the following best describes your occupation?
Primary Care Provider
Specialist (please specify specialty in "other" option)
Student (please specify area of study near "other" option)
Other:
Clear selection
Years in practice (post-residency)
Your answer
Professional Title (e.g. Director of HIV Services)
Your answer
Name of Institution
Your answer
Location of Institution
Manhattan
Brooklyn
Bronx
Queens
Staten Island
Other:
Institution Type
Hospital
Community Health Center
Medical Group
Private Practice
Health Department
Addiction Treatment Program
Other:
Clear selection
Have you treated a patient for hepatitis C in the past 3 years?
Yes
No
Clear selection
On average, how many hepatitis C patients do you treat in one year?
0
less than 10
11-24
More than 25
Clear selection
What characteristics describe the HCV positive patients at your practice?
Recent Immigrants
People who use drugs
Justice Involved
Homeless
Youth
Baby Boomers
Other:
What barriers do you face in caring for HCV positive patients at your practice?
Limited number of providers
Patients lost to follow up
Patient refusal of treatment
Patients' current drug/alcohol use
Patients' other medical co-morbidities
Limited Clinical Hours
Lack of health insurance coverage/prior authorization requirements
Other:
On average, how many HIV patients do you treat in one year?
0
less than 10
11-24
More than 25
Clear selection
Which of the following do you currently conduct in your practice? Please select all that apply
Screening and diagnosis of hepatitis C
Hepatitis C pre-treatment assessment
Treating hepatitis C, including monitoring patients during and after treatment
Assessment of hepatitis C treatment related drug-drug interactions
Screening for hepatocellular carcinoma
Fibrosis measurement
Treating hepatitis C in people infected with HIV
Treating hepatitis C in people who use drugs
Treating hepatitis C in people with mental health conditions
None of the above
Other (please specify)
Why are you choosing to take part in this training series?
To learn to treat hepatitis C
To gain additional knowledge and experience treating hepatitis C
To obtain CMEs
What do you hope to learn in this training?
Your answer
Are you interested in participating in the half-day HCV clinical preceptorship at a NYC liver clinic after this training?
Yes
No
Undecided
Other
Clear selection
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Report Abuse
-
Terms of Service
-
Privacy Policy
Forms
