200888 Instructions HIV PREVENTION FORM May 19 2008 by HC121107061418


									                                                                                                     May 19, 2008

                                  Program Evaluation and Monitoring System
                                     HIV Counseling, Testing, and Referral
                                       Instructions OMB No. 0920-0696

The HIV Test Form was developed by The Center for Disease Control and Prevention for all its Grantees.
This instruction sheet will help you in pre-test, post test, and referrals for all high risk clients. Print in all
areas that you are required to complete. Check off each box that indicates your client’s risk factor that will
produce an area for referral to help toward risk reduction for HIV infection. Remember each section builds
on the next section and any error or non entry will reject the whole event form being processed. Changes
will occur in this form when mandate changes occur by The Center for Disease Control and Prevention.

Section 1:
Enter the session date. The current date counsel, or testing, or referrals is occurring.
Enter site name or Health Unit ID number with zip code. This is called a venue and does require a full
address to be entered when the Counseling, testing, and referral is not being conducted in a county health
unit which uses county health unit ID numbers.

Section 2: Client Information
Print clients full name last, first, and middle initials
Print clients birth date = day month year
Print clients current address
Print the city, state, county, and zip code where client currently lives. (Do not enter Post Office Box
Check off clients current Gender.
Check off clients Ethnicity.
Check off clients Race.
Check off if client has had a previous HIV TEST.
Check off the results of previous HIV TEST.
Enter the date of the clients last HIV TEST.

Section 3: Risk Factors
Check off your pre-test questions about clients risk factors.
Check off clients past twelve months sexual risk factors.

Section 4: Session Activity
Check off risk reduction plan for client.
Check off boxes of session activities.

Section 5: HIV TEST
Enter pre-test sample date.
Print worker name.
Check off test election.
Check off test technology.
Check off specimen type.
Page 2

Section 5: HIV TEST
Post test
Check off results of HIV test.
Enter date post test was provided.
If results not provided explain, why.
Check off if client provided confirmatory sample.
Check off which HIV Test Strategy.

Section 6: Referrals
Check off medical care.
Check off HIV Prevention services
Check off PCRS
Check off if clients attend appointment.
Check of if no.
Check off if client is pregnant.
Check off if clients prenatal care.

Section 7: HIV Positive Incidence
Enter the date information is being collected.
Check off if client has ever tested negative.
Enter last negative HIV test.
Enter first Positive HIV test.
Enter number of HIV test client has received in past two years.
Check off if client used or is currently using Antiretroviral medications.
Enter date Antiretroviral medication began.
Enter date Antiretroviral medication was last taken.
Check off Antiretroviral medication client is using.

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