Form Information Form

SAMHSA MAI Rapid HIV Testing Clinical Information Form

----------------------------------------------------------------------------------------------------------------------------------------------------------------------

SECTION A: SITE CHARACTERISTICS

Provider ID: ____________

SAMHSA CLIENT ID: _________________ (Bar code)

Date of visit_______________________

Site ID: ________________

Site Type #: (see site code on back page)

Site code #____________________  Other (specify)________________________

RAPID TEST KIT LOT NUMBER:___________________

SECTION B: DEMOGRAPHICS

1. Gender

3. Ethnicity

5. Previous HIV Test

 Male

 Hispanic

 No

 Female

 Non-Hispanic

 Yes

 Transgender

 Result was negative

2. Age

4. Race (Check all that apply)

 Result was positive

 <18 years

 Black/African American

 Result was inconclusive

 18-24 yrs

 Asian

 Result was unknown

 25-34 yrs

 Native Hawaiian/Other Pacific Islander

 35-44 yrs

 Alaska Native

 45-54 yrs

 White

 55-64 yrs

 American Indian

 65+ yrs

SECTION C: REASON FOR TEST: _____________________________________________

SECTION D: WHAT BEHAVIORS DO YOU ENGAGE IN THAT PUT YOU AT RISK? (Check all that apply)

1. During the past 30 days have you:

q had unprotected sex with male q had unprotected sex with female

q Had unprotected sex while high on drugs/alcohol

q exchanged sex for drugs/money/shelter

q had unprotected sex with transgender individual q had unprotected sex with significant other in monogamous relationship

q had unprotected sex with person who injects drugs

q had unprotected sex with a man who has sex with men

q had unprotected sex with multiple partners

q had unprotected sex with HIV positive person

q Been diagnosed with sexually transmitted disease (syphilis, chlamydia, gonorrhea, herpes)

2. During the past 30 days have you used:

 cocaine (crack)  marijuana  methamphetamine  heroin  ecstasy  non-medical use prescription drugs

 5 or more alcoholic drinks in 1 sitting (for men)  4 or more alcoholic drinks in 1 setting (for women

 shared injection equipment (i.e. needle and drug paraphernalia)

3. Have you

 ever been in alcohol or drug treatment  been in alcohol or drug treatment during the past 12 month

 ever experienced serious psychological distress (e.g., major depression, anxiety disorder)

4. The client :  reports no known risk factors

Section E: Rapid HIV Testing

1. Rapid test results

2. Did client receive results of rapid test?

 Negative/Non-reactive

 Yes

 Positive/Reactive

 No, reason _____________________________________________

 Invalid (Repeat test using a new test kit.)

Retest Result:

 Negative/ Non-reactive

 Positive/ Reactive

 Invalid/ indeterminate

Rapid test kit lot number (client retested):_________________

Section F: TYPE OF SERVICES PROVIDED (Check all that apply)

 HIV Pre-Test/Prevention Counseling

 HIV Post-Test Counseling

 Linked to care/treatment after positive confirmatory testing  Linked to prevention/ancillary services if negative test result

Section G: Confirmatory Testing (if rapid test result is positive/reactive)

1. Confirmatory test conducted

3. Confirmatory test results

 Yes

 Negative  Indeterminate

 Yes: Client now wants a confirmatory test after initial refusal.

 Positive  Results pending

 No, reason______________________________________

2. Type of confirmatory test

4. Did client receive results of confirmatory test?

 Blood (plasma, serum, or blood spot)

 Yes

 Oral  Urine

 No, reason ______________________________

White: Complete with Rapid Test (Sections A thru F)

RETURN TO: SAMHSA Contractor

Project Number:

SAMHSA MAI Rapid HIV Testing Clinical Information Form

SECTION A: SITE CHARACTERISTICS

Provider ID: ____________

SAMHSA CLIENT ID: _________________ (Bar code)

Date of visit_______________________

Site ID: ________________

Site Type #: (see site code on back page)

Site code #____________________  Other (specify)________________________

RAPID TEST KIT LOT NUMBER:___________________

SECTION B: DEMOGRAPHICS

1. Gender

3. Ethnicity

5. Previous HIV Test

 Male

 Hispanic

 No

 Female

 Non-Hispanic

 Yes

 Transgender

 Transgender

2. Age

4. Race (Check all that apply)

2. Age

 <18 years

 Black/African American

 <18 years

 18-24 yrs

 Asian

 18-24 yrs

 25-34 yrs

 Native Hawaiian/Other Pacific Islander

 35-44 yrs

 Alaska Native

 45-54 yrs

 White

 55-64 yrs

 American Indian

 65+ yrs

SECTION C: REASON FOR TEST: _____________________________________________

SECTION D: WHAT BEHAVIORS DO YOU ENGAGE IN THAT PUT YOU AT RISK? (Check all that apply)

1. During the past 30 days have you:

q had unprotected sex with male q had unprotected sex with female

q Had unprotected sex while high on drugs/alcohol

q exchanged sex for drugs/money/shelter

q had unprotected sex with transgender q had unprotected sex with significant other in monogamous relationship

q had unprotected sex with person who injects drugs

q had unprotected sex with a man who has sex with men

q had unprotected sex with multiple partners

q had unprotected sex with HIV positive person

q Been diagnosed with sexually transmitted disease (syphilis, chlamydia, gonorrhea, herpes)

2. During the past 30 days have you used:

 cocaine (crack)  marijuana  methamphetamine  heroin  ecstasy  non-medical use prescription drugs

 5 or more alcoholic drinks in 1 sitting (for men)  4 or more alcoholic drinks in 1 setting (for women

 shared injection equipment (i.e. needle and drug paraphernalia)

3. Have you

 ever been in alcohol or drug treatment  been in alcohol or drug treatment during the past 12 month

 ever experienced serious psychological distress (e.g., major depression, anxiety disorder)

4. The client :  reports no known risk factors

Section E: Rapid HIV Testing

1. Rapid test results

2. Did client receive results of rapid test?

 Negative/Non-reactive

 Yes

 Positive/Reactive

 No, reason _____________________________________________

 Invalid (Repeat test using a new test kit.)

Retest Result:

 Negative/ Non-reactive

 Negative/ Non-reactive

 Invalid/ indeterminate

Rapid test kit lot number (client retested):_________________

Section F: TYPE OF SERVICES PROVIDED (Check all that apply)

 HIV Pre-Test/Prevention Counseling

 HIV Post-Test Counseling

 Linked to care/treatment after positive confirmatory testing  Linked to prevention/ancillary services if negative test result

Section G: Confirmatory Testing (if rapid test result is positive/reactive)

1. Confirmatory test conducted

3. Confirmatory test results

 Yes

 Negative  Indeterminate

 Yes: Client now wants a confirmatory test after initial refusal.

 Positive  Results pending

 No, reason _______________________________________

2. Type of confirmatory test

4. Did client receive results of confirmatory test?

 Blood (plasma, serum, or blood spot)

 Yes

 Oral  Urine

 No, reason ______________________________

Yellow: Complete for Confirmatory Test (Complete Section G)

RETURN TO: SAMHSA Contractor

Project Number:

SAMHSA MAI Rapid HIV Testing Clinical Information Form

SECTION A: SITE CHARACTERISTICS

Provider ID: ____________

SAMHSA CLIENT ID: _________________ (Bar code)

Date of visit_______________________

Site ID: ________________

Site Type #: (see site code on back page)

Site code #____________________  Other (specify)________________________

RAPID TEST KIT LOT NUMBER:___________________

SECTION B: DEMOGRAPHICS

1. Gender

3. Ethnicity

5. Previous HIV Test

 Male

 Hispanic

 No

 Female

 Non-Hispanic

 Yes

 Transgender

 Result was negative

2. Age

4. Race (Check all that apply)

 Result was positive

 <18 years

 Black/African American

 Result was inconclusive

 18-24 yrs

 Asian

 Result was unknown

 25-34 yrs

 Native Hawaiian/Other Pacific Islander

 35-44 yrs

 Alaska Native

 45-54 yrs

 White

 55-64 yrs

 American Indian

 65+ yrs

SECTION C: REASON FOR TEST: __________________________________________________________

SECTION D: WHAT BEHAVIORS DO YOU ENGAGE IN THAT PUT YOU AT RISK? (Check all that apply)

1. During the past 30 days have you:

q had unprotected sex with male q had unprotected sex with female

q Had unprotected sex while high on drugs/alcohol

q exchanged sex for drugs/money/shelter

q had unprotected sex with transgender q had unprotected sex with significant other in monogamous relationship

q had unprotected sex with person who injects drugs

q had unprotected sex with a man who has sex with men

q had unprotected sex with multiple partners

q had unprotected sex with HIV positive person

q Been diagnosed with sexually transmitted disease (syphilis, chlamydia, gonorrhea, herpes)

2. During the past 30 days have you used:

 cocaine (crack)  marijuana  methamphetamine  heroin  ecstasy  non-medical use prescription drugs

 5 or more alcoholic drinks in 1 sitting (for men)  4 or more alcoholic drinks in 1 setting (for women)

 shared injection equipment (i.e. needle and drug paraphernalia)

3. Have you

 ever been in alcohol or drug treatment  been in alcohol or drug treatment during the past 12 month

 ever experienced serious psychological distress (e.g., major depression, anxiety disorder)

4. The client:  reports no known risk factors

Section E: Rapid HIV Testing

1. Rapid test results

2. Did client receive results of rapid test?

 Negative/Non-reactive

 Yes

 Positive/Reactive

 No, reason _____________________________________________

 Invalid (Repeat test using a new test kit.)

Retest Result:

 Negative/ Non-reactive

 Positive/ Reactive

 Invalid/ indeterminate

Rapid test kit lot number (client retested):_________________

Section F: TYPE OF SERVICES PROVIDED (Check all that apply)

 HIV Pre-Test/Prevention Counseling

 HIV Post-Test Counseling

 Linked to care/treatment after positive confirmatory testing  Linked to prevention/ancillary services if negative test result

Section G: Confirmatory Testing (if rapid test result is positive/reactive)

1. Confirmatory test conducted

3. Confirmatory test results

 Yes

 Negative  Indeterminate

 Yes: Client now wants a confirmatory test after initial refusal.

 Positive  Results pending

 No, reason _______________________________________

2. Type of confirmatory test

4. Did client receive results of confirmatory test?

 Blood (plasma, serum, or blood spot)

 Yes

 Oral

 No, reason ______________________________

 Urine

Pink: Keep for your records

SAMHSA MAI Rapid HIV Testing Clinical Information Form

Codes for Site Types

S01 S02 S03	Inpatient Facility Inpatient Hospital Inpatient-Drug/Alcohol Treatment	S16 S17 S18	Community Setting-AIDS Service Organization-non-clinical Community Setting-Community Center Community Setting-Shelter/Transitional housing
S04 S05 S06	Inpatient Facility-Other Outpatient-Drug/Alcohol Treatment Clinic Outpatient-HIV Specialty Clinic	S19 S20 S21	Community Setting-School/Education Facility Community Setting-Residential Community Setting-Public Area
S07 S08 S09	Outpatient-Community Mental Health Outpatient-Community Health Clinic Outpatient-TB Clinic	S22 S23 S24	Community Setting-Workplace Community Setting-Commercial Community Setting-Other
S10 S11 S12	Outpatient-School/University Clinic Outpatient-Prenatal/OBGYN Clinic Outpatient-Family Planning	S25 S26 S27	Community Setting-Bar/Club/Adult Entertainment Community Setting-Church/Mosque/Synagogue/Temple Correctional Facility
S13 S14 S15	Outpatient-Private Medical Practice Outpatient-Health Department/Public Health Clinic Outpatient-Health Department/Public Health Clinic-HIV	S28	Blood Bank, Plasma Center