Registration Form

St. Louis PTC - STI Intensive Course 2023

St. Louis PTC - STI Intensive Course 2023
Virtual Classroom, MO  |  6/27/2024  |  FREE

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OMB Control Number 0920-0995
Exp. Date 06/30/2023

First Name
Middle Initial
Last Name
Degree:
Title / Position
Please write the FULL name of your organization:
Work Address
City
State
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ZIP
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Daytime Phone
Email
Birth Day (MM/DD)
New Password
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Your primary profession/discipline (select ONE that best describes your profession; If student, select goal)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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Your primary functional role (select ONE that best describes your primary role)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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Primary programmatic focus of your work (select ONE that best describes your area of work or clinical specialty)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  Other  
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Your primary employment setting (select ONE):
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  Other  
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If applicable, please select up to TWO minoritized racial and ethnic populations predominantly served by your program:
 
 
 
 
 
 
If applicable, please select up to THREE of the following special population predominantly served by your program:
 
 
 
 
 
 
 
 
 
 
 
 
 
 
How do you describe your ethnicity?
     
How do you describe your race? (select all that apply)
 
 
 
 
 
 
 
  Other  
Please select the gender that best describes your identity:
                Other  
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Do you provide services directly to clients or patients?
   
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?
     
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 STI screening, diagnosis, or treatment in an average MONTH?
         
Do you use the CDC STI Treatment Guidelines to guide the care of your patients/clients?
 
 
 
 
 
  Other  
Tooltip for Employment Setting
Please specify what source you use.
Are you aware of the STI Treatment Guide mobile app that can be used to access the CDC STI Treatment Guidelines?
 
 
 
 
  Other  
Tooltip for Employment Setting
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A member of the National Network of STD Clinical Prevention Training Centers. The NNPTC registration website is built and maintained by the Denver PTC, a program of Denver Public Health, a department of Denver Health and Hospital Authority. This Website was supported by Cooperative Agreement #5U62PS003282 from the Centers for Disease Control and Prevention. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the Centers for Disease Control and Prevention.