Clinical Quality Management Technical Assistance Request Form

Complete this form to request help from the HRSA HIV/AIDS Bureau Clinical Quality Management Technical Assistance program. 

HRSA HIV/AIDS Bureau staff will contact you within three business days of receiving the form to schedule a conference call. During the conference call, we will discuss your technical assistance request including clarifying the objectives, timelines, and expectations.

Section 1: Referral Information

Type of technical assistance:
Is this technical assistance request a result of a HIV/AIDS Bureau site visit?
Is this technical assistance request for a subrecipient(s)?

Section 2: Grant Recipient Information

Which grant(s) does the recipient receive that are directly funded by the HIV/AIDS Bureau? (check all that apply)

Section 3: Technical Assistance Location

If different than location in Section 2

Section 4: HIV/AIDS Bureau Project Officer


Section 5: Technical Assistance Objectives

Please indicate which of the following objectives you would like to accomplish through the technical assistance. Use the 'Other Objectives' to describe an objective not listed below.