CSTEP Registration  
 


CSTEP

Pulse aquí para registro en Español

*First Name:
*Last Name:
*Day Phone:
Fax:
*E-mail:
Organization:
*Mailing Address:
*City:
*State:
*Zip:
*Supervisor's Name:
*Supervisor's E-Mail:
*Supervisor's Phone:
*Have you attended a CSTEP training before? Yes  No
If Yes, please list trainings and dates:

*Is this training a requirement to perform/continue to perform your job at your agency? Yes  No
If Yes, please explain. If No, then what is your main reason for participating in this training?


* Required Fields

Below is the list of training dates. Please note that these dates are subject to change, so please verify times and dates beforehand.

You may sign up for more than one type of training.

August 26, 2014
9:00 am -4:30 pm
San Bernardino Lay of the Land Preparedness and Response Program
247 South Boyd Street
San Bernardino, CA 92415
August 27, 2014
9:00 am-4:30 pm
San Bernardino Health Care Reform and HIV Preparedness and Response Program
247 South Boyd Street
San Bernardino, CA 92415
September 29, 2014
10:00 am -5:30 pm
Sacramento Disability Income in CA Shriner's Hospital
Boardroom, 7th Floor
2425 Stockton Blvd
Sacramento, CA 95817
September 30, 2014
10:00 am- 5:30 pm
Sacramento Lay of the Land Shriners Hospital
Boardroom, 7th Floor
2425 Stockton Blvd
Sacramento, CA 95817

 


County in which you currently provide services:


Primary Employment Setting:
Rural
Suburban
Urban
Please select the population(s) that you
provide services for at your agency:
(select all that apply)

African-American
Asian
Latino/a
Native American
Pacific Islander
Caucasian/White
Other:
Please select the primary population that you provide services for at your agency:
(select ONLY one)

African-American
Asian
Latino/a
Native American
Pacific Islander
Caucasian/White
Other:

Please estimate (roughly) what percentage of
your total agency's clients are persons of color:

Very few (i.e., less than 10%)
Less than half (10% - 50%)
More than half (50% - 90%)
Almost all (> 90%)

Please estimate (roughly) what percentage of your total agency's clients identify as LGBT (Lesbian, Gay, Bisexual, Transgender):
Very few (i.e., less than 10%)
Less than half (10% - 50%)
More than half (50% - 90%)
Almost all (> 90%)
N/A
Approximate HIV+ Caseload?
Less than 10%
10 - 25%
26 - 50%
51 - 75%
76 - 99%
100%


Is your agency Ryan White-funded?
Yes
No
Don't Know/Not Sure
*Job Position (check one)
Benefits Counselor
Case Manager
Outreach Worker
Health Educator
Peer Advocate
Nurse
Physician
Clergy/Faith-Based Professional
Dietician/Nutritionist
Mental Health Professional
Public Health Professional
Social Worker
Substance Abuse Professional
Volunteer
Other:

Years specifically working in HIV/AIDS.
Less than 1 year
1 - 3 years
3+ - 5 years
5+ - 10 years
10+ years

For Benefits Training participants ONLY, do you help clients with enrollment in public benefits? If so, please check all that apply.
Medicare
Medi-Cal
SSI (Supplemental Security Income)
SSDI (Social Security Disability Insurance)
SDI (State Disability Insurance)
ADAP (AIDS Drug Assistance Program)
LIHP (Low Income Health Program)
Other:

I do not help with enrollment of public benefits

For Treatment Training participants ONLY, how much of your time (if any) is spent providing HIV education and/or treatment information to people living with HIV/AIDS?
Less than 10%
10 - 25%
26 - 50%
51 - 75%
76 - 99%
100%

Please let us know what you would like to get out of this training: (optional)



Please note: enrollment is NOT confirmed until written or verbal confirmation is received from CSTEP.
Please call to confirm registration and date.



Back to Top

 
     
Home   Contact Us   Jobs   How Can I Help   About Us   FAQ
Google 
WWW A&PI WELLNESS

730 Polk Street, San Francisco, CA 94109 | Tel 415.292.3400 | Fax 415.292.3404
©2007 A&PI Wellness Center.
This site contains HIV prevention messages that may not be appropriate for all audiences.