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* 1. Contact Information

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* 2. What is the name(s) and title(s) of the proposed mentor for this program?

Please note that at least one of the fellow's mentors must be an HIVMA member.

Clinic Patient Demographics

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* 3. Gender identity of the Clinic Patient Population (estimated percentage)

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* 4. Race/Ethnicity of Clinic Patient Population (estimated percentage)

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* 5. Does the clinic specialize in the care of any of the following populations? (Check all that apply)

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* 6. Does your clinic receive funding from HRSA’s Ryan White Program?

Clinic Training Opportunities and Experience

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* 7. As the sponsor – can you offer the opportunity for fellows to care for patients with HIV in an inpatient and outpatient setting within your institution or with an affiliated hospital?

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* 8. Will your clinic offer the opportunity for fellows to gain experience in these areas? (Check all that apply)

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* 9. How many HIV specialists are part of your care team?

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* 10. How many patients with HIV will the clinical fellow be managing (estimated amount)?

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* 11. Assuming funding from HIVMA to cover salary/benefits, will your institution be able to offer the candidate an employee benefits package?

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* 12. Will fellows have access to didactic or interactive HIV education opportunities such as Grand Rounds lectures, study groups, etc?

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* 13. Does your institution currently have an HIV Training Program?

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* 14. Is this program part of an Infectious Diseases training program?

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* 15. Does your institution have links to other clinics/programs at which fellows may spend up to 2 months of their fellowship?

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* 16. Has the fellowship been approved by your institution?

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* 17. Are you able to accommodate one clinical fellow for 1 year beginning July 1?

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