HIVMA Clinical Fellowship - Clinical Site Registration Form Question Title * 1. Contact Information Institution Address 1 Address 2 City State Zip Contact Name Phone E-mail Question Title * 2. What is the name(s) and title(s) of the proposed mentor for this program? Please note that at least one of the fellow's mentors must be an HIVMA member. Mentor Name Mentor Title Mentor Name Mentor Title Clinic Patient Demographics Question Title * 3. Gender identity of the Clinic Patient Population (estimated percentage) Male Female Transgender Male/Trans Man Transgender Female/Trans Woman If unsure, enter "N/A" Question Title * 4. Race/Ethnicity of Clinic Patient Population (estimated percentage) American Indian/Native Alaskan Asian Black/African American Hispanic/Latino Native Hawaiian/Pacific Islander White/Caucasian Other Question Title * 5. Does the clinic specialize in the care of any of the following populations? (Check all that apply) Men Who Have Sex with Men Transgender Individuals Adolescents Pregnant Women Children Question Title * 6. Does your clinic receive funding from HRSA’s Ryan White Program? Yes No Clinic Training Opportunities and Experience Question Title * 7. As the sponsor – can you offer the opportunity for fellows to care for patients with HIV in an inpatient and outpatient setting within your institution or with an affiliated hospital? Yes No Comment Question Title * 8. Will your clinic offer the opportunity for fellows to gain experience in these areas? (Check all that apply) Prescribing PrEP Diagnosing and managing hepatitis C in patients with HIV Preventing, diagnosing and treating (or referring for treatment for) substance use disorders Preventing, diagnosis and treatment (or referring for treatment for) mental health disorders Question Title * 9. How many HIV specialists are part of your care team? Question Title * 10. How many patients with HIV will the clinical fellow be managing (estimated amount)? Question Title * 11. Assuming funding from HIVMA to cover salary/benefits, will your institution be able to offer the candidate an employee benefits package? Yes No Question Title * 12. Will fellows have access to didactic or interactive HIV education opportunities such as Grand Rounds lectures, study groups, etc? Yes No Comment Question Title * 13. Does your institution currently have an HIV Training Program? Yes No Question Title * 14. Is this program part of an Infectious Diseases training program? Yes No If no, please describe. Question Title * 15. Does your institution have links to other clinics/programs at which fellows may spend up to 2 months of their fellowship? Yes No Comment Question Title * 16. Has the fellowship been approved by your institution? Yes No Question Title * 17. Are you able to accommodate one clinical fellow for 1 year beginning July 1? Yes No Done