Registration

My agency receives funding from the New York State AIDS Institute	Yes No
I am registering for Measuring Health Outcomes: Evaluation Methods for HIV Supportive Services Programs. I understand that this training is for organizations providing support services to HIV/AIDS clients. *	Yes No
I am attending the March 23-25, 2010 training (Syracuse)	Yes No
I understand that I must bring a laptop to all three days of the training. *	Yes No
Name (Last, First, MI) *
Degree
Organization *
Employer (if different) *
Organization Address (your work mailing address) *
Department or Division (if appropriate)
Job Title
Work E-mail *
Work Phone Number *
Work Fax number
Home Address
I prefer to receive training mailings at my home address.	Yes No
Cell Phone (alternative contact number)
Years in current position *
In what county do you primarily work? *
Race (American Indian or Alaskan Native, Asian, Native Hawaiian or Pacific Islander, Black/African American, White, More than one Race, Unknown/Unreported *
Are you Hispanic *	Yes No
Education Level- One Year College, 2 Year College, 3 Year College, 4 Year College, Graduate Degree, High School/GED, Less than 12 Years
Field (what is your degree in)
Work Setting (e.g. 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/Position (e.g. 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)
What population does your agency serve? (e.g. gender, age group, homeless, incarcerated, substance user, mental health)
I will need an accomodation (e.g. interpreter, listening device or other). *	Yes No
Have you had Program Evaluation Training in the past? *	Yes No