Bay Area AIDS Education and Training Center

Bay Area AIDS Education and Training Center University of California, San Francisco De partme nt of Fa mi ly and Commu ni ty M e dic ine U C S F M a i l c o d e 0 6 6 1  5 5 0 1 6 t h S t r e e t , 3 r d F l o o r , S a n F r a n c i s c o , C A 9 4 1 5 8 - 2 5 4 9  w w w . ba y a r e a a e t c . o r g HIV/AIDS Clinical Training Preceptorship Application How to Apply:  A complete Application Packet is due to SFAETC one month prior to beginning a Clinical Training Preceptorship program. A complete Application Packet includes the following items: A completed Clinical Training Preceptorship Application A completed HIV/AIDS Provider Survey A completed HIV/AIDS Medical Management Skills Assessment A signed HIPAA Confidentiality Statement A copy of your curriculum vitae (CV) or résumé  Please fill out application and survey forms completely and legibly (type or print).  Be as specific as you can in describing your current and/or future HIV-related interests and experience. Please feel free to attach any additional pages if you need more space. The information you provide will help us design a course and clinical experience which best meets your educational needs.  Send your complete application packet via email [email protected]

P A R T I C I P A N T I N F O R M A T I O N Name:

Title:

Profession/ Check one: Advanced Practice Nurse Nurse Practitioner Physician Discipline: Nurse Pharmacist Physician Assistant Current Affiliation/

Employer: Street Address: Preferred Mailing Address: City: State: ZIP Code:

This is my: Work Address Home Address OK to list contact info on roster? Yes No Alternate Daytime Phone: Phone: E-mail Address: FAX Number:

What is your current job description?

What percentage of your professional time do you spend in the following activities? % Direct HIV patient care % Community-based/related work % Teaching % HIV/AIDS policy %Other (specify): ______Please briefly describe any formal HIV/AIDS training experience you have had (certification program, fellowship, etc.):

December 2014 San Francisco Area AIDS Education and Training Center University of California, San Francisco De par tme nt of Family and Co mmun ity Me dic ine at San Fr anc isc o Ge ner al Hospital U C S F B o x 1 3 6 5  S a n F r a n c i s c o , C A 9 4 1 4 3 - 1 3 6 5  4 1 5. 2 0 6 . 8 7 3 0  F a x : 4 1 5 . 4 7 6. 3 4 5 4  w w w . u cs f . e d u / s f a e t c

L E A R N I N G G O A L S Please briefly describe how you made your decision to attend an HIV/AIDS Clinical Training Preceptorship:

In the spaces below, please list at least three (3) specific, professional or personal goals or objectives you wish to achieve by participating in an HIV/AIDS Clinical Training Preceptorship. Examples: . “I wish to increase my knowledge of HIV issues for women. I will be working in a Planned Parenthood clinic and don’t have much experience with women who have HIV.” . “I want to learn more about taking care of inmates at all stages of HIV disease.”

Please briefly describe how you will incorporate what you learn in this training program into your patient care:

C L I N I C A L E X P E R I E N C E P R E F E R E N C E S Please indicate below which clinical setting(s) you would prefer for the clinical experience component of the HIV/AIDS Clinical Training Preceptorship program (subject to availability). You may check up to two (2) preferences: Any (no preference) Primary Care HIV Specialty Clinic Inpatient Management HIV Sub-specialty Clinic Special Populations Clinic (substance use, transgender, etc. (Dermatology, neurology, etc.) Please specify: Please specify: Women’s Clinic Clinic Pharmacy (Pharmacists only) Other Retail Pharmacy (Pharmacists only) Please specify: Please list any languages you speak other than English:

If necessary, are you willing to attend a clinical experience in the evening? Yes No Please list any other special considerations regarding potential clinical experience:

A C K N O W L E D G E M E N T . I understand that I am responsible for my own travel, personal expenses and transportation while participating in the HIV/AIDS Clinical Training Preceptorship program in San Francisco. . As a participant in this educational activity, I agree to comply with the requirements associated with protected health information under the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

Signature: Date:

December 2014 H I V / AI D S P r o vi d e r S u r v e y

1) What is your primary specialty/area of practice? (Check one) Addiction Medicine OB/GYN Women’s Health Community/Public Health Oncology Other (specify)

General/Family Practice Oral/Dental Medicine None/Does Not Apply Infectious Disease Pediatrics Internal Medicine Psychiatry/Mental Health

2) Is your primary work setting/unit dedicated to serving HIV-infected patients (HIV specialty clinic?) Yes No

3) When (what year) did you see your first HIV+ patient/client? Don’t Know

4) How many hours of HIV/AIDS training did you participate in within the last year? Don’t Know

5) To help us accommodate your learning priorities and preferences, please rate your skill for each of the activities listed below by circling a number along the scale of 1 (Not Able) to 5 (Very Able):

Not Very Activity Able Able 1 2 3 4 5 Your ability to screen patients for risk of HIV infection and provide appropriate risk reduction counseling Your ability to perform an initial history and physical examination covering key areas for patients with HIV/AIDS Your ability to incorporate HIV prevention into the medical care of HIV-infected patients Your ability to prescribe and monitor antiretroviral therapy according to the DHHS Guidelines for the Use of Antiretroviral Agents in HIV-infected Adults and Adolescents Your ability to assess, monitor and treat metabolic complications of antiretroviral therapy Your ability to assess patient adherence to antiretroviral therapy and conduct interventions to promote adherence to medication regimens Your ability to manage common symptoms and side effects of antiretroviral medications Your ability to manage the major opportunistic diseases and malignancies associated with HIV infection Your ability to monitor for laboratory abnormalities in HIV disease in order to identify and manage medical problems in asymptomatic patients Your ability to evaluate exposure risk and offer recommendations for post-exposure prophylaxis (PEP) Your ability to provide appropriate care to HIV-infected women of childbearing age Your ability to address substance use problems in patients living with HIV Your ability to address mental health or psychiatric disorders in patients living with HIV Your ability to incorporate palliative care into primary HIV care and address challenges of end-of-life care for patients with advanced HIV disease

6) What types of educational/training activities are most useful to you? Please indicate the usefulness of each learning activity below by circling a number along the scale of 1 (Not Useful) to 5 (Very Useful):

Not Very Activity Useful Useful 1 2 3 4 5 Lectures/Didactics (1-2 hour lectures; onsite in-service training) Web-based/Internet (online continuing education) Workshops/Live CE Programs (½ to 1 day or longer skills-building programs) Telemedicine (videoconferencing / satellite broadcasts) Hands-on Clinical Training (i.e., mini-residencies, clinical preceptorships) Onsite Clinical Consultation (case reviews/case-based presentations)

December 2014 H I V S k i l l s As s e s s m e n t & L e a r n i n g I nt e r e s t s To help us accommodate your learning priorities, please rate your skills and level of learning interest for each of the topics below by checking the box in the appropriate column:

TOPIC AREAS SKILL ASSESSMENT LEARNING INTEREST

Basic HIV Science & Epidemiology High Medium Low High Medium Low Diagnostic Testing (CD4, viral load, resistance) Early Interventions for HIV Disease HIV Virology/Pathogenesis (Natural History) Identification of HIV Infection Primary HIV Infection Clinical Manifestations of HIV Disease Dermatological HIV-related Malignancies Metabolic Complications/Disorders Neuropsychiatric Oral Pulmonary Cardiac Antiretroviral Treatment Adherence Adverse Reactions/Side Effects Drug-drug Interactions Initiating HAART Resistance Salvage Therapy Treatment Sequencing/Strategies Co-Morbidities Hepatitis A, B, C STDs Tuberculosis Clinical Management of HIV Disease Opportunistic Infection Prophylaxis/Treatment Pain Management Immune Reconstitution Alternative/Holistic Therapies New Therapies/Clinical Trials HIV Nutrition Post-exposure Prophylaxis Management of Pediatric HIV/AIDS Women with HIV/Pregnancy Perinatal Transmission Psychosocial Issues Multi-Diagnoses (Mental Illness, Chemical Dependency) Substance Use/Abuse Harm Reduction Risk Assessment Sexual History Taking HIV Prevention/Prevention with Positives HIV Testing & Counseling

University of California San Francisco

December 2014 Confidentiality of Patient, Employee and University Business Information

Statement of Policy:

It is the legal and ethical responsibility of all UCSF faculty and staff employees, house staff, students and volunteers to use personal and confidential patient, employee and University business information (referred to here collectively as “confidential information”) in accordance with the law and University policy, and to preserve and protect the privacy rights of the subject of the information as they perform their University duties.

Laws controlling the privacy of, access to and maintenance of confidential information include, but are not limited to, the federal Health Insurance Portability and Accountability Act (HIPAA), the California Information Practices Act (IPA), the California Confidentiality of Medical Information Act (COMIA), and the Lanterman-Petris-Short Act (LPS). These and other laws apply whether the information is held in electronic or any other form, and whether the information is used or disclosed orally or in writing.

University policies that control the way confidential information may be used include, but are not limited to the following: UCSF Medical Center Policy 05.02.01, LPPI Policy, UC Personnel Policies PPSM 80, APM 160, applicable union agreement provisions, UC Business and Finance Bulletin RMP 8, and as summarized below.

Confidential information includes information that identifies or describes an individual and the disclosure of which would constitute an unwarranted invasion of personal privacy. Examples of confidential employee and University business information include home address and telephone number; medical information; birth date; citizenship; social security number; spouse/partner/relative’s names; income tax withholding data and performance evaluations and proprietary/trade secret information.

The term “medical information” includes the following: medical and psychiatric records, including paper printouts, photos, videotapes, diagnostic and therapeutic reports, x-rays, scans, laboratory and pathology samples; patient business records, such as bills for service or insurance information whether stored externally or on campus; electronically stored or transmitted patient information; visual observation of patients receiving medical care or accessing services; verbal information provide by or about a patient; peer review/risk management information and activities; or other information the disclosure of which would constitute an unwarranted invasion of privacy.

Acknowledgement of Responsibility

I understand and acknowledge that:

It is my legal and ethical responsibility to preserve and protect the privacy, confidentiality and security of all medical records, proprietary and other confidential information relating to UCSF, its patients, activities and affiliates, in accordance with the law and University policy.

I agree to access, use or disclose confidential information only in the performance of my University duties, where required by or permitted by law, and only to persons who have the right to receive that information. When using or disclosing confidential information, I will use or disclose only the minimum information necessary.

I agree to discuss confidential information only in my workplace and for University-related purposes. I will not knowingly discuss any confidential information within the hearing of other persons who do not have the right to receive the information. I agree to protect the confidentiality of any medical, proprietary or other confidential information which is incidentally disclosed to me in the course of my relationship with UCSF.

I understand that psychiatric records, drug abuse records, and any and all references to HIV testing, such as clinical tests, laboratory or otherwise, used to identify HIV, a component of HIV, or antibodies or antigens to HIV, are specially protected by law.

I understand that my access to all University electronic information systems is subject to audit in accordance with University policy.

I agree not to share my Login or User ID and/or password with anyone and that any access to UCSF electronic information systems made using my Login or User ID and password is my responsibility. If I believe someone else has used my Login or User ID and/or password, I will immediately report the use to Information Technology Services and request a new password.

I understand that violation of any of the University’s policies and procedures related to confidential information or of any state or federal laws or regulations governing a patient’s right to privacy may subject me to legal and/or disciplinary action up to and including immediate termination from my employment/professional relationship with UCSF.

I understand that I may be personally liable for harm resulting from my breach of this Agreement and that I may also be held criminally liable under the HIPAA privacy regulations for an intentional and/or malicious release of protected health information.

______Signature Date

______FCM-Bay Area & North Coast AETC__ Print Name Department

December 2014