Instructions: Module 53 - TheMeasurementGroup.com

Citation: Huba, G. J., Melchior, L. A., Staff of The Measurement Group, and HRSA/HAB's SPNS Cooperative Agreement Steering Committee (1996). Module 53: Trainee Characteristics Form. Available: www.TheMeasurementGroup.com. Culver City, California: The Measurement Group.

Answer questions by either filling in a circle, or writing a number or letter in a square box. If the answer goes in a square box, you must use a CAPITAL LETTER or number that does not touch the side of the box. Print only one letter or number in each box. If the letters or numbers that you print touch the sides of the boxes, or if you do not clearly print the information, the computer will "kick out" the form and we will need to return it to you to be completed correctly. If the question asks the answer to be filled in a circle, make sure that the circle is completely darkened. Only darken one circle for each question unless the instructions specifically tell you to darken as many as apply for that question.

ID Letters/ID Numbers. These boxes are provided for entering the unique identifier your site is using to track participant information. The four boxes on the left are to be used for letters only, while the ten boxes on the right are reserved for numbers only. If there are letters in your site's participant ID codes, write them in the boxes labeled "ID Letters." If there are numbers in your site's participant ID codes, write them in the boxes labeled "ID Numbers." If you are unsure about a client’s unique identifier, check with you project director.

Site. This is a code to identify your project in the cross-cutting evaluation. It should be pre-printed on the form. If it has not already been entered on the form, check with your project to find out your site code and enter it in the boxes. Site codes are 3 letters.

Training #. Enter the three-digit code for the training session. For example, if this is the third training or presentation that your project has held, you would enter "003" in these boxes.

Training Date. Enter the numbers representing the date of the training in these boxes. Enter the month as a number from 01 to 12 for January through December. Enter the day as a two-digit number (01 to 31). Enter the last two digits of the current year (for example, "95" for 1995). Make sure that if a month or day is less than 10, you place a "0" before the number.

Age. Instruct the trainee to enter his or her age in years in the boxes indicated.

What is your primary ethnic/cultural/racial background. Instruct the trainee to choose from among the two-digit codes provided on the form and fill in the appropriate boxes. The trainee should be as specific as possible in selecting the codes. If the trainee cannot specify subcategories of ethnic/cultural/racial background, the trainee should use the broader categories ("10" = Caucasian, "20" = African-American/Black (non-Hispanic), "30" = Hispanic, "40" = Asian/Pacific Islander, "50" = American Indian, Aleutian, Native Alaskan or Eskimo). The trainee should mark "99" if the ethnic/cultural/racial background is unknown.

Do you identify yourself as multi-racial? The trainee should darken either the "Yes," "No," or "Do Not Know" circle to indicate if he/she identifies him/herself as multi-racial. If the trainee does identify him/herself as multi-racial and has filled in the circle labeled "Yes," he/she may enter the two-digit code for the second race or ethnicity in the boxes provided. Use the same codes as those listed under "Primary Ethnic/Cultural/Racial Background."

What are your professional credentials? Instruct the trainee to darken the circle which describes his or her professional credentials. Fill in as many circles as necessary. The boxes labeled "Other" may be used to write in one response not listed on the form.

How would you characterize the organization in which you now work? Instruct the trainee to darken the circle which most closely describes the organization in which he or she is currently working. Fill in as many circles as necessary. The boxes labeled "Other" may be used to write in one response not listed on the form.

Primary Language. Instruct the trainee to darken the circle of the choice that indicates the trainee’s primary language. Choose only one. The boxes labeled "Other" may be used to write in one language not indicated on the form.

Are you taking this training primarily to allow you to train other individuals? Instruct the trainee to darken the "Yes" circle if he/she is at the training mainly to learn how to train other people. The "No" circle should be filled if he/she is not at the training mainly to learn how to train other people. The "Do Not Know" circle should be filled if he/she is not sure.

Is it likely that you will use the training you get today to train other individuals? Instruct the trainee to darken the "Yes" circle if he or she will probably use the specific information from today's training to train other people. The "No" circle should be filled if he/she will probably not use the specific information from today's training to train other people. The "Do Not Know" circle should be filled if he/she is not sure.

Are you taking this training primarily to allow you to change how you personally access services? Instruct the trainee to darken the "Yes" circle if he or she is at the training mainly to learn how to personally access services. The "No" circle should be filled if he/she is not at the training mainly to learn how to personally access services. The "Do Not Know" circle should be filled if he/she is not sure.

Is it likely that you will use today's training to help you access services for yourself? Instruct the trainee to darken the "Yes" circle if he or she will probably use the specific information from today's training to personally access services. The "No" circle should be filled if he/she will probably not use the specific information from today's training to personally access services. The "Do Not Know" circle should be filled if he/she is not sure.

How many years of "professional" experience do you have? Instruct the trainee to write in the two boxes the number of years that they have been working in their chosen field. Enter the number of years as a two-digit number. For example, if he/she has been working in their chosen field for three years, he/she would enter "03" in the boxes.

How many years of "professional" experience do you have working on HIV-related services & problems? Instruct the trainee to write in the two boxes the number of years that they have been working specifically with HIV-related issues. Enter the number of years as a two-digit number. For example, if he/she has been working specifically with HIV-related issues for three years, he/she would enter "03" in the boxes.

What is the highest level of education you have achieved? Instruct the trainee to darken the circle indicating the highest educational level achieved. Darken only one circle to indicate the highest educational level achieved at the time of the training, not taking into account any coursework in progress. For example, if he/she is currently working toward completion of a first Bachelor’s degree, he/she would darken the "High School or Equivalency" circle. The boxes labeled "Other" may be used to write in one response not listed on the form.

Which setting best represents where most of your agency's clients come from? Instruct the trainee to darken the circle(s) that best describe the setting where most of his/her agency’s clients come from. Darken as many circles as is necessary. Fill in the circle labeled "Not relevant/here to be trained to meet my own needs" if this question does not apply to the trainee.

What is your primary functional role in your job? Instruct the trainee to darken the circle indicating his/her main functional role in his/her job. The boxes labeled "Other" may be used to write in one response not listed on the form.

What is, or would be, your primary involvement with HIV+ individuals? Instruct the trainee to darken the circle(s) which best describes their primary involvement with HIV+ individuals. Fill in as many circles as necessary. The boxes labeled "Other Physician" may be used to write in a type of physician not listed on the form. The boxes labeled "Other" may be used to write in one other type of occupation not listed on the form.

What is your sexual orientation? This question is optional. Instruct the trainee to darken the "Refused" circle if he/she chooses not to respond. Instruct the trainee to darken the circle which best describes their sexual orientation. Choose only one. The boxes labeled "Other" may be used to write in one response not listed on the form.

Are you HIV positive? This question is optional. Instruct the trainee to darken the "Prefer not to answer" circle if he/she chooses not to respond. The "Yes" circle should be filled if he/she has tested HIV positive. The "No" circle should be filled if he/she has tested HIV negative. The "Do Not Know" circle should be filled if he/she does not know his/her HIV status.

How many persons with HIV/AIDS have you personally served in the past year? Instruct the trainee to darken the circle which best represents the range in number of persons with HIV/AIDS he/she has personally served in the past year. Choose only one. If he/she does not personally serve HIV-positive individuals, he/she should darken the circle labeled "Not applicable."

Approximately how many hours of HIV/AIDS education/training have you had in the past 3 years? Instruct the trainee to darken the circle which best represents the range in number of hours of HIV/AIDS education and/or training he/she has had in the past 3 years. Choose only one.

Instruct the trainee to give responses which best describe how they feel or would feel about providing care for the specific groups listed below.

A Person With...	Working Definition
HIV Infection (but not AIDS)	A person has HIV if the standard Eliza and Western Blot tests indicate the presence of HIV antibodies. Self-reported status is acceptable. Note that this question asks about persons with HIV, but not AIDS. (From HRSA URS)
AIDS	A person has AIDS if: (1) he or she has one of the 23 AIDS-defining conditions which are strongly associated with severe immune deficiency caused by HIV; (2) he or she is HIV positive, and his or her CD4+ lymphocyte count is below 200 cell per cubic millimeter of blood. (From HRSA URS)
HIV/AIDS Related Neuropsychiatric Condition	Examples of HIV/AIDS-related neuropsychiatric conditions are AIDS-related dementia and delirium.
Chemical Dependency	A person has a chemical dependency if he or she intakes a substance to excess or over a longer period than intended; or has a persistent desire or unsuccessful efforts to reduce or control substance use.
A History of Violence or Current Criminal Justice System Involvement	Examples of violence are physical assault, battery, and terroristic threatening. Persons involved with the criminal justice system include those in jail, those on parole or probation, those who have pending hearings or court dates, those with warrants for their arrest, and those under questioning or suspicion for crimes.