Intensive Complete Long-Term Evaluation (paper option)

OMB Control Number 0920-0995

Exp. Date 06/30/2023

TODAY’S DATE

____________________________

M M D D Y Y

Your confidential ID number is the first two letters of your FIRST name, the first two letters of your LAST name, the MONTH of your birth, and the DAY of your birth.

FN	FN	LN	LN	M	M	D	D

CONFIDENTIAL IDENTIFIER

Public reporting burden of this collection of information is estimated to average 6 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.  An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0995).

Intensive Long-Term Evaluation

A1f. The training is relevant to my work.

strongly disagree











Strongly agree

A2f. The training improved the way I do my work.

strongly disagree











Strongly agree

A3f. I am using what I learned in this training in my work.

strongly disagree











Strongly agree

A3fa. If you have not used what you learned, please explain why not.____________________________________

A4f. In the prior evaluation, your response to the following question, “do you intend to make changes in your practice or at your worksite setting”, was <insert user’s response from immediate post evaluation>. (Skip for those who do not have piped response from Post evaluation)

Were you able to make this change?

 Yes

 No

A4fa. If No, please explain?­­­­­­­­­­­____________________________________

A5f. As a result of the training, did you make changes in your practice or at your worksite? (Skip for those who answer A4f)

 Yes

 No

 Not my job

 Other reason (please specify)____________________________________

A5fa. If yes, what change(s) did you make?­­­­­­­­­­­____________________________________

	As a result of the information presented did you…	Yes	No	I was already doing this
SGCH1	Use the CDC STD Treatment Guidelines in your practice?	1	0	2
SGCH2	Download the CDC STD Treatment Guidelines app?	1	0	2
SGCH3	Use the STD Treatment Guidelines wall chart or pocket guide?	1	0	2
SGCH4	Send a consult to the STD Clinical Consultation Network? www.stdccn.org	1	0	2

	As a result of the information presented did you… (Select ‘Not Applicable’ if the training did not cover the content area listed)	Yes	No	I was already doing this	N/A
SGCH5	Increase the proportion of your sexually active asymptomatic female patients under age 25 screened annually for urogenital chlamydia and gonorrhea?	1	0	2	3
SGCH6	Increase the proportion of your male patients who have sex with men screened for syphilis, gonorrhea, and chlamydia at least annually?	1	0	2	3
SGCH7	Use CDC-recommended antibiotic therapy to treat uncomplicated gonorrhea?	1	0	2	3
SGCH8	Recommend rescreening in 3 months following a gonorrhea, chlamydia or trichomonas diagnosis?	1	0	2	3

A6f. Did any of these factors MAKE IT HARDER for you to incorporate the STD practices recommended in the presentation? (select all that apply)

 Lack of time with patients

 More important patient concerns

 Cost/lack of reimbursement

 Policies where i work

 Resistance to change by supervisor or colleagues

 Lack of equipment or supplies

 No opportunity to apply practices

 I did not feel confident

 Coworkers need training

 Nothing interfered

 other, please specify ___________________________________________________

A7f. Did any of these factors HELP you incorporate the STD practices recommended in the presentation?

(select all that apply

 Reimbursement or other financial incentive

 Support of supervisor and/or colleagues

 Standing orders

 Reminder in chart

 Convenient supplies

 Posted patient instructions for obtaining specimens

 Electronic health system

 Knowledge/Confidence gained from training

 Trained coworkers

 Nothing specific helped

 Other, please specify ___________________________________________________

The following questions ask about screening rates. Please select the range that is the best estimate of your screening practice.

PPC1f Now, 3 months AFTER training, approximately what % of sexually active asymptomatic female

patients under age 25 are you screening annually for chlamydia?

0%	1-25%	26-50%	51-75%	76-90%	>91%		NA
							

PPC2f Now, 3 months AFTER training, approximately what % of pregnant patients under age 25 are you

screening for chlamydia?

0%	1-25%	26-50%	51-75%	76-90%	>91%		NA
							

PPG1f Now, 3 months AFTER training, approximately what % of sexually active asymptomatic female patients

under age 25 are you screening annually for gonorrhea?

0%	1-25%	26-50%	51-75%	76-90%	>91%		NA
							

PPG2f. Now, 3 months AFTER training, approximately what % of pregnant patients under age 25 are you

screening for gonorrhea?

0%	1-25%	26-50%	51-75%	76-90%	>91%		NA
							

PPG3f Now, 3 months AFTER training, approximately what % of your male patients who have sex with men

are you screening annually for gonorrhea and chlamydia?

0%	1-25%	26-50%	51-75%	76-90%	>91%		NA
							

PPS1f Now, 3 months AFTER training, approximately what % of your male patients who have sex with men are

you screening at least once a year for syphilis?

0%	1-25%	26-50%	51-75%	76-90%	>91%		NA
							

PPS2f Now, 3 months AFTER training, approximately what % of your pregnant patients are you screening for syphilis?

0%	1-25%	26-50%	51-75%	76-90%	>91%		NA
							

PPS3f Now, 3 months AFTER training, approximately what % of your patients recently diagnosed with

syphilis are you testing for HIV?

0%	1-25%	26-50%	51-75%	76-90%	>91%		NA
							

PPHPV1f Now, 3 months AFTER training with approximately what % of your non-vaccinated 11 to 26 year-old

female patients are you discussing HPV vaccination during a preventive health visit?

0%	1-25%	26-50%	51-75%	76-90%	>91%		NA
							

PPHPV2f Now, 3 months AFTER training, with approximately what % of your non-vaccinated 11 to 21 year-old

male patients are you discussing HPV vaccination during a preventive health visit?

0%	1-25%	26-50%	51-75%	76-90%	>91%		NA
							

PPHPV3f Now, 3 months AFTER training, with approximately what % of your non-vaccinated male patients

age 26 or under who have sex with men or are HIV+ are you discussing HPV vaccination during a

preventive health visit?

0%	1-25%	26-50%	51-75%	76-90%	>91%		NA
							

PPSH1f Now, 3 months AFTER training, for approximately what % of patients older than 15 seeing you for a

preventive health visit do you take a sexual history that asks about behaviors that would put them at risk

of getting or transmitting an STD?

0%	1-25%	26-50%	51-75%	76-90%	>91%		NA
							

PPSH2f Now, 3 months AFTER training, for approximately what % of patients older than 15 seeing you for a

Preventive health visit do you take a sexual history that asks whether they have had oral, vaginal, or

anal sex?

0%	1-25%	26-50%	51-75%	76-90%	>91%		NA
							

EXPEDITED PARTNER THERAPY

EPTf As a result of the information presented do you intend to provide Expedited Partner Therapy (EPT) to

heterosexual partners of those diagnosed with gonorrhea and/or chlamydia?

 Yes

 No

 Not applicable to my practice or job

 Not allowed in my state/practice

 My practice/worksite is in the planning stages to offer EPT

 My practice/worksite already offers EPT

 EPT was not discussed