STEPS Clinical Preceptorship Intake Form

Thank you for your interest in the HIV/STBBI Clinical Preceptorship!

HIV/STBBI Clinical Preceptorship: The STEPS program coordinates opportunities for physicians and nurse practitioners who are currently practicing in Saskatchewan to participate in half or full day clinics to observe an HIV/STBBI specialist provide patient care.

Please note: Limited number of opportunities are available and participants are prioritized based on the following criteria:

1) Currently (or interested) in prescribing HIV and/or STBBI medication treatment.
2) Currently (or will) be working in a clinic with a moderate or high volume of patients who require HIV/STBBI care.
3) Have received HIV/STBBI medical education from the STEPS program.

Question Title

* 1. First name

Question Title

* 2. Last name

Question Title

* 3. Email address

Question Title

* 4. Best phone number to reach you at:

Question Title

* 5. Where do you reside (city/town)?

Question Title

* 6. What is your profession?

Question Title

* 7. Organization

Saskatchewan Health Authority (SHA)

Indigenous Services Canada (ISC)

Other (please specify, no abbreviations, please)

Question Title

* 8. Which Saskatchewan communities do you practice in? (Ex: Saskatoon)

Question Title

* 9. What clinics do you currently work at?

Question Title

* 10. Which STBBI are you interested in observing care of? Select all that apply.

HIV

Hep C

Syphilis

Other (please specify)

Question Title

* 11. Are you willing to travel to another community for this opportunity? (For example, Prince Albert, Saskatoon, Regina, or North Battleford)

Question Title

* 12. Do you have a preference for full or half day?

Full

Half

Question Title

* 13. What are your learning motivations for applying for this preceptorship?

Question Title

* 14. Are you currently enrolled as:

Designated ARV prescriber

Designated DAA prescriber

Unsure

Not applicable

Question Title

* 15. In the last 12 months, how many people living with each STBBI have you provided care to?

	Zero	1-10	11-20	21-30	31-40	41-50	51-60	60+
HIV	HIV Zero	HIV 1-10	HIV 11-20	HIV 21-30	HIV 31-40	HIV 41-50	HIV 51-60	HIV 60+	HIV
HCV	HCV Zero	HCV 1-10	HCV 11-20	HCV 21-30	HCV 31-40	HCV 41-50	HCV 51-60	HCV 60+	HCV
Syphilis	Syphilis Zero	Syphilis 1-10	Syphilis 11-20	Syphilis 21-30	Syphilis 31-40	Syphilis 41-50	Syphilis 51-60	Syphilis 60+	Syphilis

Question Title

* 16. Which statement BEST describes your current HIV clinical practice?

Not applicable - I do not provide clinical care to patients in my profession.

I am providing primary care to people living with HIV and primarily managing their ARV medication treatment. When needed, I refer patients to an HIV specialist.

I am providing primary care to people living with HIV. I refer all patients to an HIV specialist for ARV medication treatment.

I do not yet feel confident treating or providing primary care to people living with HIV. I am referring all patients to an HIV specialist.

I am a medical resident interesting in treating HIV in the future.

I provide support (case management, outreach, etc) to people living with HIV.

Other (please specify)

Question Title

* 17. Which statement BEST describes your current Hep C clinical practice?

Not applicable - I do not provide clinical care to patients in my profession.

I am treating HCV in my clinical setting. When needed, I refer patients to a HCV specialist.

I do not yet feel confident treating HCV. I am referring all patients to a HCV specialist.

I am a medical resident interested in treating HCV in the future.

Other (please specify)

Question Title

* 18. Which statement BEST describes your current syphilis clinical practice?

Not applicable - I do not provide clinical care to patients in my profession.

I am treating syphilis in my clinical setting.

I do not yet feel confident treating syphilis. I am referring all patients to public health and/or a specialist.

Other (please specify)

Question Title

* 1. First name

Question Title

* 2. Last name

Question Title

* 3. Email address

Question Title

* 4. Best phone number to reach you at:

Question Title

* 5. Where do you reside (city/town)?

Question Title

* 6. What is your profession?

Question Title

* 7. Organization

Question Title

* 8. Which Saskatchewan communities do you practice in? (Ex: Saskatoon)

Question Title

* 9. What clinics do you currently work at?

Question Title

* 10. Which STBBI are you interested in observing care of? Select all that apply.

Question Title

* 11. Are you willing to travel to another community for this opportunity? (For example, Prince Albert, Saskatoon, Regina, or North Battleford)

Question Title

* 12. Do you have a preference for full or half day?

Question Title

* 13. What are your learning motivations for applying for this preceptorship?

Question Title

* 14. Are you currently enrolled as:

Question Title

* 15. In the last 12 months, how many people living with each STBBI have you provided care to?

Question Title

* 16. Which statement BEST describes your current HIV clinical practice?

Question Title

* 17. Which statement BEST describes your current Hep C clinical practice?

Question Title

* 18. Which statement BEST describes your current syphilis clinical practice?

Question Title

* 19. Additional comments: