Asian & Pacific Islander Wellness Center

CSTEP Registration

A CSTEP Certification Training certificate is required as a pre-requisite to CSTEP Advanced Training.

Training C Registration Form

Name:
Organization:
Mailing Address:
City:
State:		Zipcode:
Day Phone:		Fax:
E-Mail:

Year and Location of completed CSTEP Certification Training (e.g. 2005, Santa Rosa):
March 5-7, 2008: Los Angeles, Advanced, ASC-AIDS Service Center 909 S. Fair Oaks Ave. Pasadena, CA 91105 Agency Information

What type of agency are you? [Check all that apply]
	Social service provider
	Medical provider
	Substance abuse or mental health provider
	AIDS-specific agency
	Agency serving a community of color
	Other:

Which of the following services does your agency provide directly? [Check all that apply.]
	Medical care and/or medications
	Substance abuse and/or mental health services
	HIV treatment information
	Case management and/or benefits counseling
	Advocacy and/or legal assistance
	HIV/STD counseling and testing
	HIV primary prevention and/or outreach and/or community education
	Other:

Client Population
[Note: May be completed just for a major program/division of a large agency.]

Approximate HIV+ Caseload?
	Less than 10%
	10-25%
	26-50%
	51-75%
	76-99%
	100%

Largest ethnic group served?
	African-American
	Asian
	Latino
	Native American
	Pacific Islander
	White
	Other:

What is the primary and secondary risk factor for your clients with HIV or those at risk of getting HIV?
Primary Risk Factors:
	Men who have sex with men
	Heterosexual women
	Injection drug users
	Heterosexual men
	Children/adolescent

Secondary Risk Factors:
	Men who have sex with men
	Heterosexual women
	Injection drug users
	Heterosexual men
	Children/adolescent

Please estimate roughly what percentage of your clients are women.
	Very few (i.e. less than 10%)
	Less than half (i.e. 10-50%)
	More than half (i.e. 50-90%)
	Almost all (i.e. more than 90%)

Please estimate roughly what percentage of your clients are transgender individuals.
	Very few (i.e. less than 10%)
	Less than half (i.e. 10-50%)
	More than half (i.e. 50-90%)
	Almost all (i.e. more than 90%)

Treatment Information [Check all that apply.]

From which of the following sources do you get HIV treatment information?
	Magazines
	Scientific or medical journals
	Newsletters
	Conferences
	Trainings
	The Internet
	E-Mail or Listservs
	Other:

On average, how often do you attend trainings, conferences, or other professional development?
	Less than once per year
	Once per year
	2-3 times per year
	3-5 times per year
	More than 5 times per year

What kinds of trainings/conferences does this include?
	In-house trainings
	Local conferences/trainings
	State or national conferences/trainings

What percentage of these trainings are HIV related?
	Very few (i.e. less than 10%)
	Less than half (i.e. 10-50%)
	More than half (i.e. 50-90%)
	Almost all (i.e. more than 90%)

Job Responsibilities

Job title: [Check One]
	Benefits Counselor
	Case Manager
	Dietician
	Health Educator
	Mental Health Counselor
	Outreach Worker
	Peer Advocate
	Prevention Worker
	Registered Nurse
	Treatment Advocate/Treatment Educator
	Substance Abuse Counselor
	Volunteer
	Other:

Do you supervise staff?
	Yes
	No

Are you the primary treatment educator at your agency?
	Yes
	No

Do you provide direct service to clients?
	Yes
	No

What types of treatment education activities do you perform? [Check all that apply]
	Individual counseling
	Support groups
	Education groups
	Retreats
	Community forums
	Other:

Please give more details regarding treatment education activities?


Is there any other information that you think is relevant?

730 Polk Street, San Francisco, CA 94109 | Tel 415.292.3400 | Fax 415.292.3404
©2007 A&PI Wellness Center.
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