200888 Copy of PEMS CT and RE vent form for venues other than Health Units 07 01 07 by YLQnN65G


									                                    ARKANSAS DEPARTMENT OF HEALTH
                                  Program Evaluation and Monitoring System
(Please Print)                     HIV Counseling, Testing, and Referral Event (07/01/2007)

1. Date of Event:                               2.   Site Name:
                                                                                                                                        (Phone Number )
3. Site Address:                                                                                  4.   City:

5. State:                    6.    Zip Code:                                          7.   County:

8. Person submitting this form:                                                                                    ID#
9.         Intervention Type              Pre-Testing                 Post Testing                     DEBI (Name)
10. Client Characteristics                                                                             Hepatitis B            1             2             3
      Clients full Name:                                                                          Clients date of Birth:
                                   (Last name)                  ( First name)              (MI)                                   ( Month       Day     Year )
                                                                            Hispanic/Latino                        Male at birth                Today
      ( Clients Address)                             (Apt#)                 Not Hispanic/Latino                    Female at birth              Today

                                                                                      Clients Race
                   (City)                             (State)               American Indian/AK Native                      Native Hawaiian / Pacific Islander
                                                                            Asian                                          White
      (Zip code)                         (County)                           Black/African American                         Don't Know
           Pregnant          In Prenatal Care                               Previous HIV Test                              In HIV Medical Care/Treatment
              Yes                  Yes                                          Yes                                        Yes
              No                   No                                           No                                         No
11.                                            Client Origin                                           Check off Type of Agency Providing Service:
                Source             (If Agency Referred)                                                    STD Clinic                       Prenatal
           Agency Referral               Counseling and Testing    C&T                                     CBO                               Obstetrics
           HC/PI                         Health Communications/Public Information HC/PI                    Contract Agency                  Tuberculosis
           Self                          Comprehensive risk counseling and services                        Family Planning                  Other
           Partner                       Health Education/Risk Reduction (DEBI)                            Drug Treatment                   Specify:
           Friend                        Partner Counseling&Referral Service PCRS                          Correctional Facility
           Family Member                 Intake / Screening                                                Hospital
                                         Outreach                                                          Private Physician/HMO
12.                                          Client Risk Factors            ( Last 3 Months )
      Incarcerated                 Recent STD(not HIV) Diagnosis                  Sex worker                 Housing Status in past
           Yes                         Yes (self-reported)                             Yes                        Permanent Housing
           No                          Yes (Lab Confirmed                              No                         Non-Permanent Housing
                                       No                                                                         Institution
      HIV Test History                                                (Check all that apply)
      Last Negative HIV test                    Risk Factors                                                 Additional Risk Factors
      Site name:                          Sex (Vaginal or anal with male)               M    F         T
                                          Sex (Vaginal or anal with female)                                  In exchange:Sex for drugs/money/other
                                          Sex (Vaginal or anal with Transgender)                             While intoxicated/or high on drugs
      State:                              Injection drug use (IDU)                                           With persons who is IDU
                                          No risk Identified                                                 With HIV Positive
      Date:                               Not asked risk factors                                             With unknown HIV status
                                                                                                             With persons who exchange sex for drugs
      Clients Relationship Status        Level of Education                                                  Known MSM
           Single and never married           No school completed                                            Did not ask
           Married or partnered               8th grade or less                                              Don't Know
           Married, Separated                 Some high school                                               Refused to answer
           Divorced                           H/S Grad, GED, equivalent
           Widowed                            Some College                      M=Male          T = Transgender
           Not asked                          Bachelor's degree                 F= Female
           Don't know                         Post grad. Degree
                                         Behavior Details
          Number of Sex Partners                          Number of unprotected sex events                  Number of unprotected sex
               (Past 90 Days)                                        ( Past 90 Days)                        events with HIV status unknown
Total sex partners                                  Total sex events                                        Partners (Past 90 Days)
HIV status Unknown                                  With IDU                                          Total number
          Number of sex events                      With Partner who                                  Male
Total number                                        exchanged sex for                                 Female
HIV status unknown                                  drugs or money                                    Transgender
          Number of needle sharing events
Total number                                  Number of unprotected sex events while intoxicated                             Elicit Partner:
HIV status unknown                            and / or on non-injected drugs:        (Past 90 Days)                          Yes
                                         Give name of non-injected drug used:                                                No

13.                                           Activities for Counseling, Testing, and Referrals
      Incentive Provided           Pre-test Activities                                          Information
           Yes                     HIV Test                                 HIV/AIDS Transmission                                  HIV/STD Counseling
           No                     Referral                               Abstinence/Postpone sex                    Partner Notification
                                  Personalized Risk Assemt               Other Sexual Transmitted Disease           Living with HIV/AIDS
                                  Elicit Partners                        Viral Hepatitis                            Social Services
                 Discussion:                          Other Testing                                          Practice
           Sexual risk reduction                       Pregnancy                                        Condom/Barrier use
           IDU risk reduction                          STD                                              IDU risk reduction
           HIV Testing                                 Viral Hepatitis                                  Negotiation/Communication
           Other sexual trans. Diseases                Tuberculosis                                     Decision making
           Disclosure of HIV status                   Demonstration                                     Disclosure of HIV status
           Partner notification                        Condom/Barrier use                               Partner notification
           HIV Medication therapy                      IDU risk reduction                                    Distribution
           Abstinence/Postpone sex                     Negotiation/Communication                        Male Condoms
           IDU risk free behavior                      Decision Making                                  Female Condoms
           HIV/STD transmission                        Disclosure of HIV status                         Safe sex kits
           Viral hepatitis                             Providing Prevention services                    Lubricants
           Living with HIV/AIDS                        Partner Notification                             Education Materials
           Sexual risk reduction                       Negotiation/Communications                       HIV Testing
           IDU risk reduction                          Decision making                                  Partner notification
           IDU risk behavior                           Disclosure of HIV status                         HIV Medication therapy
           Condom/barrier use                          Providing prevention services                    Alcohol and Drug Prevention
                                                                                                        Sexual Health
14.                                         HIV TEST                                      Test ID Number
 Test Date:                                 Test sequence number:

              Type of Test given
           Conventional                     Confirmatory of Test:                                   Specimen Type:
           Rapid             Anonymous                 Yes                                Blood-finger stick
                                                                               Blood-finger stick                  Blood spot           Urine
           Other             Confidential             No                                  Blood-venipucture
                                                                               Blood-venipucture                   Oral mcosal transudate
                             Not Tested
                 Results of TEST:                                                         If rapid reactive, did client provide conf. Sample:
           Reactive                    NAAT- Positive                                            Yes        If yes, give date:
           Non-Reactive                No Results                                                No         If no, give reason:
           Indeterminate               Positive                                                                    Refused Notification
           Invalid                     No Bands Observed                                                           Did not return/ could not locate
                                                                                                                   Obtained results form another
15.                                         Referral
      Referral date:                             Service given client:       ( Check only one)
                                                 HIV Testing                                                IDU risk reduction services
      Month Day        Year                      HIV Confirmatory test                                      Substance abuse services
                                                 HIV Prevention counseling                                  General medical care
      Referral follow-up method:                 STD screening and treatment                                PCRS
           Active referral                       Viral hepatitis screening and treatment                    Mental health services
           Passive referral- agency              Tuberculosis testing                                       Comprehensive risk counseling
           verification                          Syringe exchange services                                  Other HIV Prevention services
           Passive referral - client             Reproductive health services                               Other support services
           verification                          Prenatal care                                              Case management (PCM)
           NONE                                  HIV medical care/ evaluation/ treatment                    Other
16.                                     Referral Outcome
        Confirmed - accessed service:
Give agency name where client was referred:                              Confirmed - did not access services                 Close date:
                                                                         No follow - up                                 Month Day      year
17. Health Communications/Public Information                        Outreach                                     DEBI
           Presentation/Lectures e.g. AIDS/STD 101                       Total number of sessions                       Session Number
           Total number of sessions                                      Total number of Clients
           Total number of Clients                                            Total Minutes                                  Total Minutes
                 Total Minutes
18.                                         Reason for being Tested:
      Concerned that you have been exposed to HIV / Hepatitis B                      It was requested by an agency
      You get tested routinely                                                       Other reasons
      You are just checking to make sure you are HIV negative
                                                                               Pre-test / DEBI
                 Route Documents to:             Contact:
      Arkansas Department of Health              501-661-2168                        (Workers Signature )                               ( Date)
      4815 West Markham                                                        Post Test
      AIDS/STD Slot H-33
      Little Rock, Arkansas 72205                                                    (Workers Signature )                               ( Date)

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