I. General Information

Name:


Date:


E-mail address:


Address:

City:


State or Province:


Zip or Postal Code:


Country:


Is this your work or home address?
Work
Home

Phone Number:


Fax Number:


Degree:


Organization:


Medical or Nursing License Number:


State or Country where you are licensed:


When would be your earliest available time to participate in an overseas program?


Are there other dates later this year or next year that you would be available? When?


If your dates are flexible, how far in advance would you need to be notified in order to be able to participate?


How long is the maximum period of time you would be available to spend overseas?


Where is your current practice located?


Are you affiliated with any teaching hospitals?
Yes
No

If so, which one?

Do you have medical/nursing experience in developing countries?
Yes
No

If so, which ones?

And for how long?

Do you have travel experience in developing countries?
Yes
No

If so, which ones?

And for how long?

Do you speak other languages?
Yes
No

Please list all languages and level of proficiency:


Do you have a preference for a particular country or continent? Please rank.


Do you have related teaching/clinical experience?
Yes
No

Please explain.


What is your clinical specialty?


Has your license ever been revoked or suspended?
Yes
No

If so, please explain.


Would you be comfortable in a location without electricity or running water (this is not a requirement to volunteer; you will not be sent to a location without electricity or running water unless you indicate that is something you are comfortable with)?
Yes
No

How did you find out about ICEHA?
Colleague
Talk by ICEHA Staff Member
Email
Former ICEHA clinical mentor
Google
Other Website, please specify
ICEHA booth at conference, specify conference
Flyer/brochure at conference, specify conference
Article/Journal, specify publication
Other, please specify

II. HIV Experience (please provide very detailed information about your HIV experience so our partners in developing countries can determine if your experience would be a good match for their program needs)

What is your level of experience in terms of providing clinical care for HIV patients?
Less than three years
Three to seven years
Eight to ten years
More than eleven years

Do you currently work in a clinic that specializes just in HIV?
Yes
No

Do you work exclusively with HIV-infected patients?
Yes
No

If not, what percentage of your patients are HIV-infected?

How many HIV patients do you see each week?

How many HIV patients does your clinic/department see each week?

How many of your colleagues (MD or RN) also see HIV patients in your clinic?

Do you have specialized HIV training (CMEs, AAHIVM certified, etc)?
Yes
No

If so, please specify.

Do you have HIV experience in the following areas? Check all that apply.
ART/ARV
Clinic Management Experience
Drug Treatment
Methadone Dispensing
Palliative Care
Prevention of Mother to Child Transmission (PMTCT)
STIs
TB
Voluntary Counseling and Testing (VCT)

If so, please explain.

Do you have any experience caring for HIV-infected children?
Yes
No

If so, please explain.

Do you have any additional information about your HIV experience that is relevant?