HIV CTL Course Training Request

A skills-based course for HIV Counseling, Testing, and Linkage (CTL) professionals is called the HIV Counseling, Testing, and Linkage Course. To be eligible for certification and participation in the course, participants must comply with the following requirements:

Please use the same email address to register for your Public Health Academy account.
Participants are required to attend the complete in-person or online course.
Participants are required to engage fully in the course and demonstrate the abilities they have learned.
We’ll evaluate the skill level of each participant.
A DPH-funded HIV testing and counseling facility must be the sponsor of the participant, either directly or indirectly.
Approximately 7–14 days before the chosen course date, accepted applicants will get an email confirming their registration. You will be informed if you are not accepted for this course and given the reason why.
The GA DPH State Office does not cover travel-related costs like hotel, meals, or parking or mileage charges.

First Name *

Last Name *

Email Address *

Agency/Organization/Clinic *

Street Address *

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Work Phone Number *

Alternate Phone Number

Fax Number

Occupation/Position/Title *

Supervisor Name *

Supervisor Phone *

Supervisor Email *

List all HIV Testing Technology

Please rate your level of competency/experience in the collection of specimens by fingerstick.

Please select preferred date *

Please select your district *

Insti Testing Information

Once you have selected your testing technology with your district/agency please enter your INSTI certificate number issued by BioLytical or please visit http://www.insti.com/courses to take the online modules to obtain an INSTI Certificate.

Insti Testing Certificate Number *

Additional Requests

Enter any additional date requests here.

Please check the box below for Statement of Accuracy. *STATEMENT OF ACCURACYI certify that I have answered the above questions truthfully and to the best of my knowledge and I have reviewed this application with my Supervisor who has approved my attendance at this training.

NOTE:

This box must be checked, or the registration will be rejected.

Questions: Please email the HIV Training and Development Specialist at cicely.richard@dph.ga.gov

Tech Support contact: courtney.clarke@dph.ga.gov

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