New York State Dental Foundation: Contact Us

1. To create your unique ID number, use the month of your birth, the day of your birth, and the last four digits of your SSN. For example, May
29, 123-45-6789 has the ID number 05296789.

2. Date of training (Enter today's date, mm/dd/yy)

3. Your primary professional discipline (Select one)

4. Your primary function (Select one)

5. Your principal employment setting (Select one)

If you responded "NOT WORKING" to question #5, please skip to question #9.

6. Primary employment setting / zip code:

Zip Code:

7. Is the employment setting a faith-based organization?

8. Does the employment setting receive Ryan White Program Funding?

If you answered "don't know," please write the full name of your employer:

9. Are you of Hispanic, Latino/a or Spanish origin?

10. Your racial background (select all that apply):

American Indian / Alaska Native

Asian

Black or African American

Native Hawaiian / Other Pacific Islander

White

11. Your gender:

12. Do you provide services directly to clients/patients?

13. Do you provide services directly to HIV-infected clients/patients?

14. How many years have you been providing services directly to HIV infected clients/patients? (Round up to the nearest whole year.)

15. Estimate the NUMBER of HIV-infected clients/patients to whom you provide direct services in an average MONTH.

If you responded "NONE," you are done with this form and may click SUBMIT.

For questions 16-18, estimate the PERCENTAGE of your HIV-infected clients/patients in the past YEAR who were:

16. Racial or ethnic minorities:

17. On antiretroviral therapy:

18. Women:

Thank you for taking the time to complete this electronic participant information form (PIF). Please note that no identifying information
has been collected and that your responses are entirely anonymous. This data will be supplied only to the U.S. Department of Health
and Human Services Health Resources and Services Administration.

You may now continue to the online course -- Rapid HIV Testing in the Dental Setting (3 MCE Home Study Credits).

DIRECTIONS:
The New York State Dental Foundation is pleased to offer this course, Rapid HIV Testing in the Dental
completion for 3 MCE Home Study Credits by e-mail. In order to gain access to the course, you will need to
complete the Participant Information Form (PIF) below which does not contain any identifying information, but
is merely used to collect data for the United States Department of Health and Human Services Health Resources
and Services Administration (HRSA).

After submitting this online form, you will receive the link needed to begin the online course. Should you
have any questions, please contact us at (800) 255-2100, ext. 282.

DISCLAIMER: NYSDF’s sponsorship of continuing education courses does not constitute any warranty of the
products, techniques, procedures, or methods used or taught in such courses.

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