HIV Carceral Linkage to Care Community of Practice Registration 2025-2026

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* 1. Email Address

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* 2. First Name

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* 3. Last Name

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* 4. Credentials

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* 5. Job Title

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* 6. What is your primary profession/discipline? Select one.

Dentist

Other Dental Professional

Nurse Practitioner (prescriber)

Nurse or Other Nursing Professional (non-prescriber)

Midwife

Pharmacist

Physician

Physician Assistant

Mental/Behavioral Health Professional

Substance Use Treatment Professional

Social Worker or Case Manager

Community Health Worker (includes peer educator or navigator)

Practice Administrator or Leader (e.g. chief executive, nurse administrator)

Other Allied Health Professional (e.g. medical assistant, podiatrist, physical therapist)

Other Public Health Professional

Other Non-clinical Professional (e.g. front desk staff, grant writer, etc.)

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* 7. Clinic or Organization

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* 8. Work Zip Code

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* 9. Primary county where you work

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* 10. State

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* 11. Work Setting - Check all that apply

Community Based Organization

Correctional Facility

Dental Health Facility

Emergency Department

Indian Health Services/Tribal Clinic

Maternal/Child Health Clinic

Mental Health Clinic

Substance Use Treatment Clinic

Pharmacy

Primary Care Clinic

Military or Veterans' Health Facility

State or Local Health Dept

None Apply/Not Listed

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* 12. Do you work at a Federally Qualified Health Center (FQHC)?

Yes

Don't know

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* 13. What percent of your total patient population are racial-ethnic minorities?

None

1-24%

25-49%

50-74%

75% or more

N/A - I don't have patients

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* 14. Do you provide treatment for substance use disorder at your clinic?

Yes

N/A I'm not a prescriber

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* 15. Do you provide services directly to clients with HIV?

Yes