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Chart Participant Registration Form: First Name Last Name MI Dob (Dd/Mm//Yyyy) Gender

This document is a registration form for participants in a CHART training course. It collects contact information, demographic details, and professional details about the participant such as their job, facility type, health discipline, and experience providing clinical services. It also tracks the participant's pre-and post-training scores if applicable, comments from trainers, participation costs, and funding sources. The trainer must sign off on the completed form.

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Defitria Wardhani
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46 views

Chart Participant Registration Form: First Name Last Name MI Dob (Dd/Mm//Yyyy) Gender

This document is a registration form for participants in a CHART training course. It collects contact information, demographic details, and professional details about the participant such as their job, facility type, health discipline, and experience providing clinical services. It also tracks the participant's pre-and post-training scores if applicable, comments from trainers, participation costs, and funding sources. The trainer must sign off on the completed form.

Uploaded by

Defitria Wardhani
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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CHART PARTICIPANT REGISTRATION FORM

To be completed by the Participant:


____________________________________________________________________________________________________

First Name Gender: M F

Last Name

MI

DOB (DD/MM//YYYY)

Name of Course: __________________________________ Date of Course:_____________________________ PLEASE COMPLETE IF INFORMATION HAS CHANGED OR IF YOU ARE REGISTERING FOR THE FIRST-TIME AS A CHART PARTICIPANT: Indicate the primary Facility in which you work:
____________________________________________________________________________________________________ Facility Name Street/PO Box ____________________________________________________________________________________________________ City Province/County Country Postal Code ____________________________________________________________________________________________________ Professional e-mail Personal e-mail Professional telephone

Please Check one of the following to indicate the Facility Type: Hospital Health Center/Clinic Pharmacy Training Center Facility Sponsor: Government NGO/Not-for-Profit

Medical/Nursing/Other School Government/NGO

Other

Private/For Profit

What type of health professional are you? Check one. Enrolled/Trained Clinical Registered Registered with a Degree Nurse/ ward assistant Nurse Nurse-Midwife Midwife Public Health Family Nurse Practitioner

Physician

Dental services

Dentist Dental hygienist Dental technician

Paramedical

Intern/Resident General OB/GYN Internist Pediatrician Infectious Disease Family Practitioner Public Health Med Technician Nursing auxiliary/ ward assistant Attendants Nutritionist Nutrition technician Contact investigator Pharmacist Pharmacist Technician

Laboratory Health Services Administrator Communitybased worker Student

Laboratory Scientist Phlebotomist Technologist Administrator/Manager Accompagnateur/ Community worker Agent Sante/Health Aide Agent Femme Matrones/Traditional Birth Attendant (TBA) Please list discipline:_____________

Pharmacy

Social Services

Social Worker Counselor

Other

Other, please specify:

CHART PARTICIPANT REGISTRATION FORM


What are your current job responsibilities? Check one in each category, if applicable.
1) Primary Direct service provider Trainer, Educator Administrator/Manager Other, please specify: 2) Secondary Direct service provider Trainer, Educator Administrator/Manager Other, please specify:

Are you currently caring for any HIV/AIDS patients? Yes If yes, how many HIV patients do you see in a typical week? How many of the patients you are caring for are on ARVs? Do you currently provide any clinical services for STI, TB or other OIs? Yes No If yes, what clinical services do you provide? No

The following information to be completed by Trainer and Training Program staff: Scores (if applicable): Pre-Training Score: Post-Training Score: Not Applicable Participant did not complete activity Explain: Participant shows interest in being a ( Clinical trainer Classroom trainer Comments regarding this participant: Check all that apply): % Course Participation Costs: Subsistence/Per Diem: Time Off: Tuition: Other: Total: Funded By:

Trainer Name:

Trainer Signature:

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