Spring 2019 HCV Provider Training-Registration Form
Please complete the entire form and submit by 5/9
First Name
Your answer
Last Name
Your answer
E-mail Address
Your answer
Phone Number
Your answer
How did you hear about this program?
Have you taken part in any other hepatitis C training courses in the past 12 months?
If yes, when and where
Your answer
Credentials (please select all that apply)
Which of the following best describes your occupation?
Years in practice (post-residency)
Your answer
Professional Title (e.g. Director of HIV Services)
Your answer
Name of Institution
Your answer
Location of Institution
Institution Type
Have you treated a patient for hepatitis C in the past 3 years?
On average, how many hepatitis C patients do you treat in one year?
What characteristics describe the HCV positive patients at your practice?
What barriers do you face in caring for HCV positive patients at your practice?
On average, how many HIV patients do you treat in one year?
Which of the following do you currently conduct in your practice? Please select all that apply
Why are you choosing to take part in this training series?
What do you hope to learn in this training?
Your answer
Are you interested in participating in the half-day HCV clinical preceptorship at a NYC liver clinic after this training?
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