Nurse Practitioner Training in HIV Prevention and Treatment

Program Registration

Disclaimer

Nurse Practitioner Training in HIV Prevention and Treatment is available to nurse practitioners who hold practicing registration in British Columbia with the College of Registered Nurses of BC.

The BC Centre for Excellence in HIV/AIDS (BC-CfE) is subject to the Freedom of Information and Protection of Privacy Act of BC. We are committed to safeguarding the security and privacy of your personal information. The BC-CfE collects your personal information via this form in order to provide you with this educational service. We only collect the personal information required for this purpose and will not use it for any other purpose than the provision of educational and clinical services, including program monitoring and evaluation and research. We will not share your information without your consent unless required by law.

1. Which program are you registering for?

Tier 1: Treatment for HIV prevention (PEP/PrEP)

2. Have you previously completed the BC-CfE Intensive Preceptorship Training program?

Yes
No

In what year did you complete the program?

3. Last Name

4. First Name

5. CRNBC Registration No.

6. MSP Billing No.

7. Phone number

8. Email address

9. Who are you employed by?

Employer:

10. Please provide your current employment information:

Clinic/program name:

Work address - Street:

City:

Province:

Postal Code:

Work phone number:

Work fax number:

Add additional employment/
workplace:

11. Is your employer aware of your application for additional training?

Yes
No

12. Please provide employer contact information

Name:

Phone number:

Email address:

13. Please provide employer “Bill To” information

Organization name:

Billing address - Street:

City:

Province:

Postal Code:

Email address:

Attention:

14. Do you work with at-risk populations?

Yes
No

15. Is there at least one physician treating HIV positive patients at your practice?

Yes
No

16. Do you work in an underserved or remote area?

Yes
No

17. Comment below if there is any additional information that is relevant to your application.