HIV Provider Cultural Competency Self-Assessment
Completion and return of this survey indicate voluntary consent to participate in this study. The survey will take approximately 15 minutes to complete. Thank you for your participation.
1. Your primary profession/discipline (Select one)
*
Physician
Dentist
Other Dental Professional
Nurse
Nurse Practitioner
Other Advanced Practice Nurse
Pharmacist
Physician Assistant
Dietitian/Nutritionist
Health Educator
Mental Health Professional
Public Health Professional
Social Worker
Substance Abuse Professional
Other
If "Other" selected above (please specify)
2. Did you receive your medical/clinical education training in the U.S?
Yes
No
Received a combination of training abroad and in the U.S.
3. Do you provide services directly to patients/clients who are diagnosed with HIV? (Select one only)
*
No
Yes,directly
4. How many years have you been providing services directly to clients/patients living with HIV/AIDS? (Round up to the nearest whole year)
5. During the past year, approximately how many patients living with HIV or AIDS did you serve?
6. Which description best describes your current practice or place of employment? (Check one only)
*
Private Medical Practice
Community-Based Organization (CBO)
Community Health Center
STD/Family Planning Clinic
Community Mental Health Center
Substance Abuse Treatment Facility
Correctional Facility
Hospital or Hospital Based Clinic
Other
If "Other" selected above (please specify)
7. In what state and zip code do you provide the majority of the HIV care you deliver and/or manage?
State:
-- select state --
AL Alabama
AK Alaska
AS American Samoa
AZ Arizona
AR Arkansas
CA California
CO Colorado
CT Connecticut
DE Delaware
DC District of Columbia
FM Federated States of Micronesia
FL Florida
GA Georgia
GU Guam
HI Hawaii
ID Idaho
IL Illinois
IN Indiana
IA Iowa
KS Kansas
KY Kentucky
LA Louisiana
ME Maine
MH Marshall Islands
MD Maryland
MA Massachusetts
MI Michigan
MN Minnesota
MS Mississippi
MO Missouri
MT Montana
NE Nebraska
NV Nevada
NH New Hampshire
NJ New Jersey
NM New Mexico
NY New York
NC North Carolina
ND North Dakota
MP Northern Mariana Islands
OH Ohio
OK Oklahoma
OR Oregon
PW Palau
PA Pennsylvania
PR Puerto Rico
RI Rhode Island
SC South Carolina
SD South Dakota
TN Tennessee
TX Texas
UT Utah
VT Vermont
VI Virgin Islands
VA Virginia
WA Washington
WV West Virginia
WI Wisconsin
WY Wyoming
Zip Code:
8. Please select
ONE
to
THREE
of the most numerous high risk HIV populations (excluding racial and ethnic minorities) that receive services from your institution/department.
Elderly (over 60)
Adolescents
Incarcerated/parolees
Migrant
Homeless
Substance Users/Chemical Dependents
Gay/Bisexual/MSM
Lesbian/Bisexual/WSW
Transgender
Severely Persistently Mentally Ill
Physically Challenged
Hearing Impaired
Rural Populations
