2025-26 HIV/Hep C Clinical Preceptorship Intake Form

Thank you for your interest in the HIV/Hep C Clinical Preceptorship Program.

The STEPS program coordinates opportunities for physicians and nurse practitioners who are currently practicing in Saskatchewan to participate in half or full day clinics to observe an STBBI specialist provide patient care.

Please note: Limited number of opportunities are available and participants are prioritized based on the following criteria:

1) Currently (or interested) in prescribing HIV and/or Hep C medication treatment.
2) Currently (or will) be working in a clinic with a moderate or high volume of patients who require HIV/Hep C/STBBI care.
3) Have received HIV/Hep C/STBBI continuing medical education from the STEPS program.

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1. First name (Required.)

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2. Last name (Required.)

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3. Email address (Required.)

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4. What is your profession? (Required.)

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5. Which organization do you belong to: (Required.)

Saskatchewan Health Authority (SHA)

Indigenous Services Canada (ISC)

Other (please specify, no abbreviations, please)

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6. Which Saskatchewan community do you reside in? (Required.)

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7. Which Saskatchewan communities do you practice in? (Ex: Saskatoon) (Required.)

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8. If applicable, what is the name of the clinic(s) that you currently work at?

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9. Which STBBIs are you interested in observing care of? Select all that apply. (Required.)

HIV

Hep C

Other (please specify)

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10. Are you willing to travel to another community for this opportunity? (For example, Prince Albert, Saskatoon, Regina, or North Battleford) (Required.)

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11. Do you have a preference for a full or half day experience? (Required.)

Full Day

Half Day

No Preference

Other (please specify)

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12. Are you currently enrolled onto SK Drug Plan as a: (Required.)

Designated ARV prescriber

Designated DAA prescriber

Unsure

Not applicable

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13. In the last 12 months, how many people living with each STBBI have you provided care to? (Required.)

	Zero	1-10	11-20	21-30	31-40	41-50	51-60	60+
HIV	HIV Zero	HIV 1-10	HIV 11-20	HIV 21-30	HIV 31-40	HIV 41-50	HIV 51-60	HIV 60+
Hep C	Hep C Zero	Hep C 1-10	Hep C 11-20	Hep C 21-30	Hep C 31-40	Hep C 41-50	Hep C 51-60	Hep C 60+
Syphilis	Syphilis Zero	Syphilis 1-10	Syphilis 11-20	Syphilis 21-30	Syphilis 31-40	Syphilis 41-50	Syphilis 51-60	Syphilis 60+

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14. Which statement BEST describes your current HIV clinical practice? (Required.)

I do not yet feel confident treating or providing primary care to people living with HIV. I am referring all patients to an HIV specialist.

I am providing primary care to people living with HIV. I refer all patients to an HIV specialist for ARV medication treatment.

I am providing primary care to people living with HIV and primarily managing their ARV medication treatment. When needed, I refer patients to an HIV specialist.

I am a medical resident interesting in treating HIV in the future.

Other (please specify)

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15. Which statement BEST describes your current Hep C clinical practice? (Required.)

I do not yet feel confident treating or providing primary care to people with Hep C. I am referring all patients to a Hep C specialist.

I am providing primary care to people who have Hep C. I refer all patients to an Hep C specialist for DAA medication treatment.

I am providing primary care to people with Hep C and primarily managing their DAA medication treatment. When needed, I refer patients to an Hep C specialist.

I am a medical resident interesting in treating Hep C in the future.

Other (please specify)

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16. Which statement BEST describes your current syphilis clinical practice? (Required.)

Not applicable - I do not provide clinical care to patients in my profession.

I do not yet feel confident treating syphilis. I am referring all patients to public health and/or a specialist.

I am treating syphilis in my clinical setting.

Other (please specify)

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17. Which statement BEST describes your current syphilis clinical practice? (Required.)

Not applicable - I do not provide clinical care to patients in my profession.

I do not yet feel confident treating syphilis. I am referring all patients to public health and/or a specialist.

I am treating syphilis in my clinical setting.

Other (please specify)

2025-26 HIV/Hep C Clinical Preceptorship Intake Form

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1. First name (Required.)

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2. Last name (Required.)

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3. Email address (Required.)

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4. What is your profession? (Required.)

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5. Which organization do you belong to: (Required.)

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6. Which Saskatchewan community do you reside in? (Required.)

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7. Which Saskatchewan communities do you practice in? (Ex: Saskatoon) (Required.)

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8. If applicable, what is the name of the clinic(s) that you currently work at?

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9. Which STBBIs are you interested in observing care of? Select all that apply. (Required.)

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10. Are you willing to travel to another community for this opportunity? (For example, Prince Albert, Saskatoon, Regina, or North Battleford) (Required.)

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11. Do you have a preference for a full or half day experience? (Required.)

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12. Are you currently enrolled onto SK Drug Plan as a: (Required.)

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13. In the last 12 months, how many people living with each STBBI have you provided care to? (Required.)

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14. Which statement BEST describes your current HIV clinical practice? (Required.)

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15. Which statement BEST describes your current Hep C clinical practice? (Required.)

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16. Which statement BEST describes your current syphilis clinical practice? (Required.)

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17. Which statement BEST describes your current syphilis clinical practice? (Required.)

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18. Why are you interested in participating in a HIV and/or Hep C Clinical Preceptorship? (Required.)

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19. Additional comments:

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* 1. First name (Required.)

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* 2. Last name (Required.)

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* 3. Email address (Required.)

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* 4. What is your profession? (Required.)

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* 5. Which organization do you belong to: (Required.)

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* 6. Which Saskatchewan community do you reside in? (Required.)

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* 7. Which Saskatchewan communities do you practice in? (Ex: Saskatoon) (Required.)

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* 8. If applicable, what is the name of the clinic(s) that you currently work at?

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* 9. Which STBBIs are you interested in observing care of? Select all that apply. (Required.)

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* 10. Are you willing to travel to another community for this opportunity? (For example, Prince Albert, Saskatoon, Regina, or North Battleford) (Required.)

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* 11. Do you have a preference for a full or half day experience? (Required.)

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* 12. Are you currently enrolled onto SK Drug Plan as a: (Required.)

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* 13. In the last 12 months, how many people living with each STBBI have you provided care to? (Required.)

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* 14. Which statement BEST describes your current HIV clinical practice? (Required.)

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* 15. Which statement BEST describes your current Hep C clinical practice? (Required.)

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* 16. Which statement BEST describes your current syphilis clinical practice? (Required.)

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* 17. Which statement BEST describes your current syphilis clinical practice? (Required.)

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* 18. Why are you interested in participating in a HIV and/or Hep C Clinical Preceptorship? (Required.)

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* 19. Additional comments:

1. First name (Required.)

2. Last name (Required.)

3. Email address (Required.)

4. What is your profession? (Required.)

5. Which organization do you belong to: (Required.)

6. Which Saskatchewan community do you reside in? (Required.)

7. Which Saskatchewan communities do you practice in? (Ex: Saskatoon) (Required.)

8. If applicable, what is the name of the clinic(s) that you currently work at?

9. Which STBBIs are you interested in observing care of? Select all that apply. (Required.)

10. Are you willing to travel to another community for this opportunity? (For example, Prince Albert, Saskatoon, Regina, or North Battleford) (Required.)

11. Do you have a preference for a full or half day experience? (Required.)

12. Are you currently enrolled onto SK Drug Plan as a: (Required.)

13. In the last 12 months, how many people living with each STBBI have you provided care to? (Required.)

14. Which statement BEST describes your current HIV clinical practice? (Required.)

15. Which statement BEST describes your current Hep C clinical practice? (Required.)

16. Which statement BEST describes your current syphilis clinical practice? (Required.)

17. Which statement BEST describes your current syphilis clinical practice? (Required.)

18. Why are you interested in participating in a HIV and/or Hep C Clinical Preceptorship? (Required.)

19. Additional comments: