Center for Health and Behavior Training

Registration Form

Additional Needs: Should anyone registering for a course need a sign-language interpreter, listening device, or other accommodations, please contact us as soon as possible, so we may make the proper preparations for your attendance.

Course Name:

Date(s) of Course:

First Name:	MI:	Last Name:
Suffix:	Degree:
Organization:	Employer (if different):
Organization Street Address:	Organization City:
Organization State:	Organization Zip + four:
Department:	Job Title:
Home Street Address:	Home City:
Home State:	Home Zip + four:
Home Phone:	Business Phone: Ext:
Business Fax:	E-mail address:

Are you a member of any Prevention organization?
Community Planning Groups
Health Department
Rochester Area Task Force on AIDS
STD Prevention Planning Partners
Prevention Planning Group
Other:

Where/how did you learn about the Center for Health and Behavioral Training and our trainings?
Previously Attended Courses
Employer
Course Advertisement Flyer
Colleague/Co-worker
Other

Primary Work Setting
AIDS Treatment Center
Alcohol/Drug Treatment
CBO/Community Agency
Child Welfare Services/Foster Care
Correctional Facility
Educational Institution
EMS/Police/Fire
Family Planning/PCAP
Health Center
Health Department
Hospital
Mental Health Services
Non-Institutional Nursing Services
Nursing Home/Adult Day Care
Other
Physician’s Office/Lab

Occupation:
Administrator/Program Manager
COBRA CFW – Community Follow-up Worker
COBRA CM/CMT – Case Mgr or Case Mgr Tech
Community Educator/Outreach Worker
Counselor/Therapist
Criminal Justice/Law Enforcement
Domestic Violence Provider
Emergency Personnel
HIV Test Counselor
MR/MH Worker
Nurse
Nurse Practitioner/Physician’s Asst
Other:
Physician
Social Worker/Case Manager
Teacher/Trainer/Student

Educational Level:
College 1
College 2
College 3
College 4
Graduate Degree
High School/GED
Less than 12 years

Education Major:
Graduate Degree, Type and Field:

Ethnicity:
Not Hispanic or Latino(a)
Hispanic or Latino(a)

Race:
American Indian or Alaskan Native
Asian
Black or African American
More Than One Race
Native Hawaiian or Pacific Islander
Unknown/Unreported
White

Gender/Gender Identity:
Male Female Other, specify if desired.

Years in Current Occupation:
0 –1
2 –4
5 –7
more than 8

Employer County:

Target Populations served by your agency (Check all that apply)
Gay and Bisexual Persons
Homeless
Racial/Ethnic Groups
Sex Industry Workers
Incarcerated Persons
Youth and Adolescents
Women/Reproductive Health
Persons Living with HIV/AIDS
Health Care Providers
Students
Substance Users
Other, specify:

Types Of STD/HIV preventive services provided by your agency (Check all that apply)
Individual Client Counseling
Peer Education
Group Counseling/Support Services
Outreach
HIV Antibody Testing
HIV/AIDS Treatment
STD Testing/Treatment
STD/HIV Education Programs
Case Management
Partner Referral Services
Community Org./Coalition Bldg.
Reproductive Health Services
Primary Care
Domestic Violence Services
Rape Crisis Services
Substance Use
Other:

Other prevention services your agency offers:
Smoking Cessation
Adolescent Health
Weight Loss
Stress Reduction
Cardiovascular Health
Violence Prevention
Anger Management
Conflict Resolution
Other: