Registration Form

St. Louis PTC - STD Intensive (2 Days Webinar)

St. Louis PTC - STD Intensive (2 Days Webinar)
Webinar,  |  2/06/2020  |  $75.00

Public Burden Statement:  The information on this form is collected under the authority of 42 U.S.C., Section 243 (CDC).  The requested information is used only to process your training registration and will be disclosed only upon your written request.  Continuing education credit can only be provided when all requested information is submitted.  Furnishing the information requested on this form is voluntary.

Public reporting burden of this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.  An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0995).

OMB Control No. 0920-0995
Exp. Date:  5/31/2020

First Name
Last Name
Title / Position
Please write the FULL name of your organization:
Work Address
Birth Day (MM/DD)
New Password
Please re-type your new password
Your primary profession/discipline (select ONE):
Tooltip for Professional Discipline
Your primary functional role (select ONE):
Tooltip for Functional Role
Your principal employment setting (select ONE):
Tooltip for Employment Setting
What is the primary programmatic focus of your work (select up to TWO):
What is your racial background: (check all that apply)?
Are you of Hispanic, Latino/a, or Spanish origin?
Your gender:

The National Network of STD Clinical Prevention Training Centers would like to know:

Do you provide direct services to patients/clients who are ages 15-19?
Do you provide direct services to patients/clients who are ages 20-24?
Do you provide direct services to patients/clients who are pregnant women?
Do you provide direct services to patients/clients who are men who have sex with men?
Please estimate the NUMBER of patients/clients to whom you provide STD screening, diagnosis, or treatment in an average MONTH?
Do you use the CDC STD Treatment Guidelines to guide the care of your patients/clients?
Please specify what source you use.
Are you aware of the STD Treatment Guide mobile app that can be used to access the CDC STD Treatment Guidelines?