Adapted from Tambaram Center for Excellence in Clinical ...
Pre-training:
Clinical Questionnaire
The following pre-training questionnaire will serve several purposes. With the information you provide, we will be able to 1) make sure we meet your training needs, 2) follow-up with you after the training course, and 3) notify you about future training opportunities. Please complete the following pre-training data sheet. This information will only be used for training-related purposes.
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|Individual Information |
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|First Name: |Last name: |
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|Contact numbers |Mailing address: |
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|Cell: | |
|Office: | |
|Fax: | |
|E-mail address: | |
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|Please indicate your primary responsibility: |What type of facility do you work in? |
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|Physician – general medicine |Hospital |
|Physician – infectious diseases |Urban health center |
|Physician – other specialty _____________________ |Rural health center |
| |Other _______________________________ |
|Nurse |(Please specify) |
|Nursing assistant | |
|Laboratory technician | |
|Pharmacist | |
|Administrator | |
|Dentist | |
|Other _____________________________ (Please specify) | |
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|Pre-Training Questions |
| |Number: |
|How many total patients have you seen in the past month? | |
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|How many patients with clinical manifestations of HIV+ |Number: |
|infection have you seen in the past month? | |
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|If you have not seen any HIV patients in the past month, | |
|please tell us why. | |
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|How would you feel about your own child playing with an |Concerned |
|HIV-positive child? |Somewhat concerned |
| |Not at all concerned |
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|Please rate your willingness to care for HIV patients. |Very willing |
| |Somewhat hesitant |
| |Unsure |
| |Do not want to work with HIV+ patients |
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| |Please explain: |
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|Please rate your ability to care for HIV patients in a |I am very knowledgeable and skilled |
|clinical setting. |I have moderate skills |
| |I have few skills |
| |I have never worked with HIV+ patients |
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| |Please explain: |
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|Please rate your comfort in caring for HIV patients? |Very comfortable |
| |Somewhat uncomfortable |
| |Very uncomfortable |
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| |Please explain: |
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|What HIV/AIDS-related training do you need to enhance your | |
|work with patients and families? | |
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|What are the obstacles to caring for HIV patients in your |Sterilization material not available |
|clinic or hospital? (Select as many as apply) |Other patients wouldn’t like it |
| |Concern for your own health |
| |Don’t know enough about HIV to care for patients |
| |Other |
| |______________________________ |
| |(Please specify) |
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Please review the following list of topics and give some thought to what you currently know about each. Circle the number that best represents your level of knowledge and skills now, before training.
RATING SCALE: 1 = LOW 3 = MEDIUM 5 = HIGH
|Self-assessment of Knowledge and Skills Related to: |Pre Training |
|Natural History of HIV Infection |1 |2 |3 |4 |5 |
|Clinical Diagnosis of HIV/AIDS |1 |2 |3 |4 |5 |
|Dermatological Manifestations in HIV/AIDS Patients |1 |2 |3 |4 |5 |
|STD and HIV/AIDS |1 |2 |3 |4 |5 |
|Hands-on care of HIV/AIDS patients (ward rounds) |1 |2 |3 |4 |5 |
|Laboratory Diagnosis of HIV |1 |2 |3 |4 |5 |
|Voluntary Counseling and Testing |1 |2 |3 |4 |5 |
|Universal Precautions and Hospital Infection Control |1 |2 |3 |4 |5 |
|Post-Exposure Prophylaxis |1 |2 |3 |4 |5 |
|Continuum of HIV/AIDS Care |1 |2 |3 |4 |5 |
|Prevention of Mother to Child Transmission (PMTCT) |1 |2 |3 |4 |5 |
|Global and Your Country’s Scenario of HIV/AIDS |1 |2 |3 |4 |5 |
|HIV & TB Co-Infection |1 |2 |3 |4 |5 |
|HIV Testing Policy |1 |2 |3 |4 |5 |
|Medical Management of HIV/AIDS |1 |2 |3 |4 |5 |
|HIV Vaccines |1 |2 |3 |4 |5 |
|Anti-Retroviral Therapy |1 |2 |3 |4 |5 |
Adapted from Tambaram Center for Excellence in Clinical Training on HIV/AIDS Care, 2004, Chennai, India
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