Form Individual Dosage Individual Dosage Individual Dosage Form

National Minority SA/HIV Prevention Initiative

INDIVIDUAL DOSAGE FORM

Instructions: For each program encounter with a participant on an individual (i.e. one-on-one) basis, enter the:

1. Encounter Date

2. Grant ID

3. Five-digit Participant ID Number

For each service type received during the encounter being recorded, circle the appropriate Individual Service Code (the list of service codes are provided on the last page of this form). Record the amount of time in minutes the service type lasted (rounded up to the next 5-minute interval) in the corresponding Duration Code space. On this form, up to four services can be coded for each encounter date (this form has space for two encounter dates).

The Study Design Group Type (1=intervention group [pre-filled]), and the Administration Format (1=individual/one-on-one format [pre-filled]) boxes are only used in CSAP’s record keeping procedures.

Encounter Date

Month			Day				Year				Grant ID											Grp.Typ.			Adm. Frmt.		Participant ID #
											S		P									1			1
Individual Service Code																													Duration Code
#1		01		02		03			03a			04				04a			05				06		06a
		07		08		09			10			11				11a			11b				12		13				(Round up to next 5-minute interval)
#2		01		02		03			03a			04				04a			05				06		06a
		07		08		09			10			11				11a			11b				12		13				(Round up to next 5-minute interval)
#3		01		02		03			03a			04				04a			05				06		06a
		07		08		09			10			11				11a			11b				12		13				(Round up to next 5-minute interval)
#4		01		02		03			03a			04				04a			05				06		06a
		07		08		09			10			11				11a			11b				12		13				(Round up to next 5-minute interval)

Encounter Date

Month			Day				Year				Grant ID											Grp.Typ.			Adm. Frmt.		Participant ID #
											S		P									1			1
Individual Service Code																													Duration Code
#1		01		02		03			03a			04				04a			05				06		06a
		07		08		09			10			11				11a			11b				12		13				(Round up to next 5-minute interval)
#2		01		02		03			03a			04				04a			05				06		06a
		07		08		09			10			11				11a			11b				12		13				(Round up to next 5-minute interval)
#3		01		02		03			03a			04				04a			05				06		06a
		07		08		09			10			11				11a			11b				12		13				(Round up to next 5-minute interval)
#4		01		02		03			03a			04				04a			05				06		06a
		07		08		09			10			11				11a			11b				12		13				(Round up to next 5-minute interval)

INDIVIDUAL SERVICE CODES

INDIVIDUAL SERVICES
Code	Service	Code	Service
01	Risk Reduction and/or Resiliency Strength Assessment	06 06a	HIV Education STD Education
02	Risk Reduction Counseling/Education	07	Hepatitis Education
03	HIV Testing Counseling	08	Mentoring (Peer or Other Type)
03a	HCV Testing Counseling	09	Case Management Services
04	Psycho-Social Counseling	10	All Other Individual Services
04a	Substance Abuse Counseling
05	Substance Abuse Education
INDIVIDUAL HEALTH CARE SERVICES
Code	Service
11	HIV Testing	12	Primary Health Care Services
11a	HCV Testing	13	Other Health Care Services
11b	Other STD Testing

CSAP HIV Individual Dosage Form – Last Updated 5/2015 Page 3