Training Request Form Main contact for event coordination(Required) First Name Last Name Phone Number Main contact Email address(Required) What format would you like this presentation?(Required) Live in-person event Webinar Live in person, recorded for future use. check all that apply. Date preference for presentation(Required) MM slash DD slash YYYY 2nd Date preference for presentation(Required) MM slash DD slash YYYY 3rd Date preference for presentation MM slash DD slash YYYY Event Location:(Required) Location Name Address Line City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Best time frames for training(Required) 8am-11am 11am-2pm 2pm-5pm check all that apply. Note, training typically last between 60-90 minutes. What types of providers will take part in this training?(Required) Physicians Physician Assistants Nurses Nurse Practitioners Pharmacists Dentists Medical Case Managers Other Check all that applyDo you intend to open this event to the public?(Required) Yes No Would you like us to pursue continuing education credits for participants?(Required) Yes No Which topics would you like us to present?(Required) HIV Pre and Post Exposure Prophylaxis Motivational Interviewing for Providers Client Engagement and Retention in HIV Care Pregnancy/Perinatal HIV Care HIV in Pulmonary Disease Developing Post Exposure Prophylaxis Protocols Testing, Epidemiology and Prevention of HIV Other (enter in box below) Other Topic not listed above:
