May 19, 2008 Program Evaluation and Monitoring System (PEMS) 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 Numbers) 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.
Pages to are hidden for
"200888 Instructions HIV PREVENTION FORM May 19 2008"Please download to view full document