PAETC



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Your Name: ____________________________________ Title: __________________________________

License Type: (circle one) MD/DO, PharmD, PA, RN, NP, PHN, DDS, Other ______________

Are you an Indian Health Service or Tribal Health Facility Employee? ____YES _______NO

Do you CURRENTLY provide services to HIV positive patients? ________ Approx No. patients/month?___________

Name of Employer __________________________________________________________________________________

Name/Phone of Supervisor ___________________________________________________________________________

Work Mailing Address: _______________________________________________________________________________

___________________________________________________________________________________________________

Work Phone: _______________________________________________________________________________________

Work FAX: _________________________________________________________________________________________

Email Address: _____________________________________________________________________________________

Mobile or Pager: ____________________________________________________________________________________

___________________________________________________________________________________________________

I agree that upon acceptance into this program, I will provide my license number or the last 4 of my SS#, evidence of a negative PPD dated within the past 12 months and follow all HIPAA and UCI guidelines for clinical observation/participation. I also agree to participate in post-training outcomes evaluations and surveys.

Signed _____________________________________________________________________________

For further course information, please contact:

MAI Program at (714) 456-7612 or e-mail b2hernan@uci.edu

The University of California, Irvine

AIDS Education & Training Center

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Please EMAIL or FAX this form to:

Blanca Guardado

Fax: (714) 456-7169

E-mail: b2hernan@uci.edu

Phone: (714) 456-7734 for any questions

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Which session would you like to attend?

___ Jan. 12, 13, 14, 2015

___ March 23, 24, 25, 2015

___ May 11, 12, 13, 2015 – OPEN

Course will be presented at UCI – City Tower

333 West City Blvd. - Suite 400

Orange, CA 92868

Intended Audience

Physicians, Nurses, Nurse Practitioners, Physician Assistants and Pharmacists who are involved in the care of HIV/AIDS in minority populations.

Program Goal

To increase the quality of HIV/AIDS care and treatment for minorities living with HIV. This program will provide a three-day HIV/AIDS clinical training practicum that covers the spectrum of HIV disease for targeted health care providers working with HIV minorities.

Program Objectives

Upon completion of this three-day educational program the participants should be able to:

Have an understanding of the natural history of HIV infection, and use laboratory testing in establishing the diagnosis of HIV Infection.

Assess when to initiate antiretroviral therapy.

Summarize long-term complications of antiretroviral therapy and understand the management of drug toxicity.

Understand the role of resistance assays and its use in clinical management.

Increase knowledge and skill in caring for adults with HIV infection through direct observation in the out-patient clinic and participation in case discussions.

Apply the concepts of cultural sensitivity in delivering care to minority patients by understanding minority Health care traditions.

Understand the clinical treatment and management of Pediatric HIV Infection and utilize treatment standards in the care of the pediatric patient.

Continuing Education Certificates

Information on obtaining the continuing education certificate will be available on the first day of the course.

Faculty

The course is taught by faculty at the University of California, Irvine AIDS Education and Training Center. The faculty members are actively involved in the care and treatment of HIV infected patients.

The course is free to all participants, including travel and lodging. Federal employees must pay their own travel and lodging.

Registration is required as the enrollment is limited to five participants per session - you may register by email or fax. Upon acceptance, you will be required to submit evidence of a negative PPD or chest x-ray dated within 12 months of date of attendance.

For more information, please contact:

Blanca Guardado

Ph: (714) 456-7734

Fax: (714) 456-7169

Email: b2hernan@uci.edu

Scheduled Course Dates

____ Jan. 12, 13, 14, 2015

____ March 23, 24, 25, 2015 - OPEN

____ May 11, 12, 13, 2015 - pending

Accreditation Statement

The University of California, Irvine School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

Credit Designation Statement

The University of California, Irvine School of Medicine designates this live activity for a maximum of 24 AMA PRA Category 1 Credits™ per session. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Disclosure Statement

It is the policy of the University of California, Irvine School of Medicine and the University of California CME Consortium to ensure balance, independence, objectivity and scientific rigor in all CME activities. Full disclosure of conflicts and conflict resolutions will be made prior to the activity in writing via handout materials, insert, or syllabus.

AB 1195 CULTURAL AND LINGUISTIC COMPETENCY

This activity is in compliance with California Assembly Bill 1195 which requires continuing medical education activities with patient care components to include curriculum in the subjects of cultural and linguistic competency. For specific information regarding Bill 1195 and definitions of cultural and linguistic competency, please visit the CME website at cme.uci.edu.

ADA Statement

In compliance with the Americans with Disabilities Act, we will make every reasonable effort to accommodate your needs. For any special requests, please call (714) 456-7734.

Sponsorship:

This program has been funded through the University of California, Irvine School of Medicine and a federal grant from HRSA (Health Resources and Services Administration) as a supplement to the University of California Irvine’s AIDS Education and Training Center. HRSA grant award number 5 H4A HA 00016-02.

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