Training Request Form Main contact for event coordination* First Name Last Name Phone Number Main contact Email address* What format would you like this presentation?* Live in-person event Webinar Live in person, recorded for future use. check all that apply. Date preference for presentation* MM slash DD slash YYYY 2nd Date preference for presentation* MM slash DD slash YYYY 3rd Date preference for presentation MM slash DD slash YYYY Event Location:* 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* 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?* 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?* Yes No Would you like us to pursue continuing education credits for participants?* Yes No Which topics would you like us to present?* HIV Pre and Post Exposure Prophylaxis Motivational Interviewing for Providers Client Engagement and Retention in HIV Care Cultural Competency in HIV Care Transgender/MSM/LGBTQ HIV Care Pregnancy/Perinatal HIV Care HIV in Pulmonary Disease Developing Post Exposure Prophylaxis Protocols Fourth Generation Testing, Epidemiology and Prevention of HIV Other (enter in box below) Other Topic not listed above:
