eCOMPAS
Learning Center
HIV Confidentiality Training Registration Form
TRAINING APPLICANT INFORMATION:
*
Last Name :
*
First Name :
*
Agency Name :
*
Job Title :
*
Work Address : (Street, Room, Floor, Borough, State)
*
Work Email :
*
Work Phone :
*
Work Zip Code :
UserID
*
Provider Contract Type:
Ryan White
HOPWA
*
Have you ever taken an HIV Confidentiality Training?
Yes
No
*
Do you work directly with consumers living with HIV/AIDS?
Yes
No
*
Are you an eSHARE user?
Yes
No
*
Are you an eCOMPAS user?
Yes
No
*
Have you been to a formal training with DOHMH?
Yes
No
SUPERVISOR INFORMATION
*
Supervisor's Name :
*
Supervisor's Title :
*
Supervisor's Phone :
*
Supervisor's Email :