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Public Interest: AIDS

Office on AIDS Network Questionnaire

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*First name
 Middle name
*Last name
 Prefix           Suffix       
 Highest degree MD
PhD
PsyD
EdD
MA
MS
MSW
Other 
*Email Address
*Mailing Address
*City
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*Zip
 Country
 Telephone
 Work Phone
 Fax Number


WORK ACTIVITIES

HIV/AIDS Research (check all that apply)
Topic Areas
HIV prevention
HIV mental health services
Psychological reactions to HIV disease
Coping with HIV disease
Attitudes about HIV/AIDS
Neuropsychological aspects of HIV/AIDS
Ethical issues
Other 

Populations
Adolescents
Injection drug users
Alcohol & substance abuse (non-IDU)
Men who have sex with men
Lesbians
Children
Women
Seriously mentally ill
Military personnel
Deaf/hard of hearing
Native Americans /Alaska Natives
Asians / Pacific Islanders
African Americans
Latino / Latina
Families/Significant Others
Caregivers
People with hemophilia
Incarcerated persons
Rural communities
Sex workers
Other 


HIV/AIDS Mental Health Service Delivery (check all that apply)
Services Offered
Counseling/ psychotherapy
Support groups
Neuropsychological assessment of HIV disease
Psycho-educational workshops
Other 

Populations
Adolescents
Injection drug users
Alcohol & substance abuse (non-IDU)
Men who have sex with men
Lesbians
Children
Women
Seriously mentally ill
Military personnel
Deaf/hard of hearing
Native Americans /Alaska Natives
Asians / Pacific Islanders
African Americans
Latino / Latina
Families/Significant Others
Caregivers
People with hemophilia
Incarcerated persons
Rural communities
Sex workers
Other 


College/University Teaching (check all that apply)
Name of college / university  
Teach an HIV/AIDS course
Teach course which contains HIV/AIDS content
Supervise practicum Students working with HIV/AIDS clients
Other 


AIDS-Related Community-Based Organizations
Name of organization

What does your organization do?

Describe what you do  


HIV/AIDS Consulting
Describe what you do  


Substance Abuse Service Delivery
Inpatient
Outpatient
Outreach for persons not in treatment

Describe what you do  


HIV/AIDS Management/Administration
Name of organization

What does your organization do?

Describe what you do  


HIV Prevention Community Planning (check all that apply)
I have been involved with CDC's HIV Prevention Community Planning Program.
I would like to get involved in Community Planning.
I have not heard of CDC's HIV Prevention Community Planning.
Please send me information about Community Planning.


Number of years working in the HIV /AIDS field
Less than 1 year
3 to less than 5 years
5 years or more


What is your gender?
Male   Female


Ethnicity (check all that apply)
African American
Carribean-American
Caucasian
Latino / Latina
Asian / Pacific Islander
Native American / Alaska Native
Other 


APA Memberships (check all that apply)
Member
Assoc. Member
APA division (specify #) 
Fellow
Student Affiliate
International Affiliate
Teacher Affiliate
State or provincial psychological association (specify below)
       




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