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Indiana PrEP Interest Survey

The Midwest AIDS Training + Education Center - Indiana (MATEC-IN) would like to identify clinics (clinicians and administrators) that are interested in participating in a two-day PrEP Summit.  Your response to this survey is greatly appreciated and will assist us in program planning.    

If you have any questions, please contact Rachel Fogleman, Programming Coordinator, at rfoglema@iu.edu or (317) 880-3517.
1.Your Name
2.Clinic Name
3.Your Role/Title within Clinic
4.Clinic Address
5.Your Email
6.Your Phone Number
7.Please briefly describe your clinic (i.e. clinic type, funding, patients services, HIV/STI services):
8.Which of the following HIV services does your clinic provide (check all that apply):
9.If you are currently providing PrEP, how many patients do you have on PrEP?
10.If your clinic does not currently provide PrEP, what is the biggest barrier impacting PrEP provision? Where do you refer patients for PrEP services?
11.If your clinic does not currently provide PrEP, are you working to provide PrEP within the next 12 months?
12.Are you currently monitoring how many patients are inquiring about PrEP?
13.Your clinic administrative leadership believes that PrEP is an important HIV prevention tool that should be offered in your clinic.
14.In general, your clinic staff agrees that PrEP is an important HIV prevention strategy that the clinic should provide.
15.Which best describes how you are currently managing PrEP care for patients eligible for PrEP (check all that apply):
16.Do you have someone on staff you can dedicate to helping patients acquire health insurance, medication assistance, and other services related to PrEP?
17.Which of the following payment methods do you accept in your clinic:
18.Do you have the capability to bill and/or collect payment for HIV services, including PrEP?
19.Would you be willing to participate in a two-day training on PrEP capacity building and implementation?
20.How far would you be willing to travel for PrEP training opportunities?
Current Progress,
0 of 20 answered