Form RHHT Testing Form RHHT Testing Form RHHT Testing Form

OMB No. 0930-0343
Expiration Date: XX/XX/20XX
Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB
control number. The OMB control number for this project is 0930-0343. Public reporting burden for this collection of information is estimated to average 8 minutes per
respondent, per year, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing
the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden,
to SAMHSA Reports Clearance Officer, 1 Choke Cherry Road, Room 2-1057, Rockville, Maryland, 20857.

SAMHSA MAI Rapid HIV/HEPATITIS Testing Clinical Information Form
SECTION A: SITE CHARACTERISTICS
2. Grantee #:
4. CLIENT RHHT ID #:
6. Site type code # (see site code on back page)

1. Date of visit (mm/dd/yyyy):
_____ 3. Partner ID (if applicable):
_____ 5. GPRA ID #: ___________________  GPRA Tool Not Completed
____

RAPID HIV TEST KIT LOT NUMBER: _________________________________________________________________
SECTION B: DEMOGRAPHICS
1. Gender
5. Previous HIV Test
6. Previous Viral Hepatitis Test
3. Race
4. Age
(check one)
(check all that apply)
(check one)

Male

<18 years 
Yes

No

Yes

No

Alaska Native/

Female

18-24 yrs
If Yes: (check one)
If Yes: (check one)
American Indian

Result was negative

Transgender

Asian

25-34 yrs

Result was negative

Black/African American

35-44 yrs

Result was positive

Result was positive

Native Hawaiian/

45-54 yrs

Result was inconclusive

Result was inconclusive
2. Ethnicity
Other Pacific Islander

55-64 yrs 
Result was unknown

Result was unknown
(check one)

W hite

65+ yrs



Hispanic






Non-Hispanic
SECTION C: RISK BEHAVIORS
1. During the past 30 days have you - from the date of this form (check all that apply)

had unprotected sex with a male

had unprotected sex with a person who injects drugs

had unprotected sex with a female

had unprotected sex with a man who has sex with men

had unprotected sex with a transgender individual

exchanged sex for drugs/money/shelter

had unprotected sex with significant other in a monogamous

been diagnosed with sexually transmitted disease
relationship
(syphilis, chlamydia, gonorrhea, herpes)

had unprotected sex with multiple partners

refusal

the client reports no known sexual risk factors

had unprotected sex with an HIV positive person

had unprotected sex with an Hepatitis positive person

had unprotected
whilehave
high you
on drugs/alcohol
2. During
the past sex
30 days
used: from the date of this form (check all that apply)

4 or more alcoholic drinks

marijuana

non-medical use of prescription drugs
in 1 sitting (for men)

ecstasy

shared injection equipment (i.e. needle and drug paraphernalia)

3 or more alcoholic drinks

heroin

refusal
in 1 sitting (for women)

methamphetamine

the client reports no known substance use risk factors

cocaine (crack)

inhalants (specify)_____________ 
other (specify)
3. Have you (check all that apply)
been diagnosed with alcohol or drug dependence, in the
past 12 months

been in alcohol or drug treatment in the past 12 months

ever been in alcohol or drug treatment
SECTION D: Rapid HIV TESTING RESULTS
1. Rapid HIV test result (check one)

Negative/Non-reactive


Positive/Reactive


Invalid (Repeat test)


Refusal

been diagnosed with psychological distress, in the past 12 months
(e.g., major depression, anxiety disorder)

ever received treatment for psychological distress during the past
12 months? (e.g., major depression, anxiety disorder)

none of the above
SECTION E: Rapid HEPATITIS B & C TESTING RESULTS, if applicable
1. Rapid Hepatitis test results (check all that apply)
 Hepatitis B

Positive/Reactive

Negative/Non-reactive

Invalid (Repeat test)

Refusal

Hepatitis C

Positive/Reactive


Negative/Non-reactive

Invalid (Repeat test)

Refusal

2. Did client receive result of rapid HIV test? (check one)

Yes

No

2. Did client receive results of rapid HEP test? (check one)

Hep B
Yes

No
Hep C
Yes

No

3. Retest HIV Result: (check one)
Positive/Reactive
Negative/Non-reactive

Invalid/Indeterminate
N/A





3. Retest HEP Result: (check one)
 Hepatitis B
Hepatitis C

Positive/Reactive

Positive/Reactive

Negative/Non-reactive

Negative/Non-reactive

Invalid (Repeat test)

Invalid (Repeat test)

Refusal

Refusal
(check one)
4. 
Did client receive retest results of test?
Hep B
Yes

No
Hep C
Yes

No

4. Did client receive retest result of test? (check one)

Yes

No

OMB No. 0930-0343
Expiration Date: XX/XX/20XX
SECTION F: CONFIRMATORY TESTING of HIV
(if rapid HIV test result is positive/reactive)
1. Confirmatory HIV test result (check one)
Negative/Non-reactive
Positive/Reactive
Invalid/indeterminate

Results pending

SECTION G: CONFIRMATORY TESTING of HEP B & C Test, if applicable
(if rapid Hepatitis test result is positive/reactive)
1. Confirmatory HEP B test result (check one)
Negative/Non-reactive
Positive/Reactive
Invalid/indeterminate

Results pending

2. Type of confirmatory test (check one)

Blood (plasma, serum, or blood spot)

Oral 

Urine

2. Confirmatory HEP C test result (check one)
Negative/Non-reactive
Positive/Reactive
Invalid/indeterminate

Results pending


SECTION H: TYPE OF HIV SERVICES PROVIDED

SECTION I: TYPE OF Hepatitis SERVICES PROVIDED, if applicable

(Check all that apply)
HIV Pre/Post- Prevention Counseling

(Check all that apply)
Hepatitis Pre/Post- Prevention Counseling

HIV Pre/Post-Test Counseling
HIV Testing
Referred to HIV Care and Treatment Services


Linked to HIV care treatment after positive confirmation
(Client attended a routine HIV medical care visit within 3
months of HIV diagnosis)

Linked to HIV prevention/ancillary services if negative

test result

 Hepatitis Pre/Post-Test Counseling
Viral Hepatitis Testing
Hepatitis Vaccination
Dose 1

Yes A
___/___/___
Dose 1
B
___/___/___

A&B
Dose 1
(Twinrix)___/___/___

Dose 2
___/___/___
Dose 2
___/___/___
Dose 2
___/___/___

Dose 3
___/___/___
Dose 3
___/___/___


No (If no, reason?) _______________________________________
Referred to Hepatitis Care after positive confirmation



Linked to Hepatitis care treatment after positive confirmation
(Client attended a routine Hepatitis medical care visit within 3 months of
Hepatitis diagnosis)

Linked to Hepatitis prevention/ancillary services if negative





test result 

SAMHSA MAI Rapid HIV Testing Clinical Information Form
-------------------------------------------------------------------------------------------------------------------------------------------

Codes for Site Types
Inpatient Facility
S01
S02 S03 Inpatient Hospital
Inpatient-Drug/Alcohol Treatment
Inpatient Facility-Other
S04
S05 S06 Outpatient-Drug/Alcohol Treatment Clinic
Outpatient-HIV Specialty Clinic
Outpatient-Community Mental Health
S07
Outpatient-Community Health Clinic
S08
Outpatient-TB Clinic
S09
Outpatient-School/University Clinic
S10
S11
Outpatient-Prenatal/OBGYN Clinic
S12
Outpatient-Family Planning
S13
Outpatient-Private Medical Practice
S14 S15 Outpatient-Health Department/Public Health Clinic
Outpatient-Health Department/Public Health Clinic-HIV

Community Setting-AIDS Service Organization-non-clinical
S16
S17 S18 Community Setting-Community Center Community
Setting-Shelter/Transitional housing
Community Setting-School/Education Facility
S19
S20 S21 Community Setting-Residential
Community Setting-Public Area
Community Setting-Workplace
S22
Community Setting-Commercial
S23
Community Setting-Other
S24
Community Setting-Bar/Club/Adult Entertainment
S25
S26
Community Setting-Church/Mosque/Synagogue/Temple
S27
Community Setting-Mobile Unit
S28
Correctional Facility
Blood Bank, Plasma Center
S29