Provider Survey 2008

Name of Agency: 
Address: 
Telephone Number: 
Facsimile: 
Email Address: 
Contact Person and Title: 

In what location/region does your agency provide HIV/AIDS services?
 

Which of these options best describes your agency?
AIDS service organization
Health clinic
Community based organization (Not AIDS specific)
Hospital
Multi-service agency that includes HIV/AIDS services
Substance abuse treatment facility
Other 

How many years have your agency provided HIV/AIDS care related services?
 

Do you target a particular population?
 

If so, who? (Please specify)
Race/ethnicity: 
Gender: 
Age Group: 
Special Needs: 

Which of the following does your agency most often provide?
Medical care
Dental care
Case management
Substance abuse treatment
Food distribution/nutrition
Counseling/mental health
Access (Child care, transportation, etc.)
Housing
Benefits/financial assistance
Family services
Other 

How are the costs of client services covered?
Ryan White CARE Act
Access TN
Medicare
Private insurance
Self pay
Uncompensated
Other 

Please indicate needs within your service areas that are not provided for people with HIV/AIDS.
 

From your organization`s viewpoint, please identify barriers encountered in providing services to people with HIV/AIDS.
Size of population 
Waiting list 
Time set aside 
Staff HIV experience 
Staff bias 
Client/patient stigma 
Community bias 
Cultural competency and sensitivity 
Geographic location 
Proximity to public transportation 
Service hours 
Eligibility requirements 
Language barriers 
Please Enter Code Into the Textbox Below (CODE IS CASE-SENSITIVE):

 

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