Attachment 2d

Attachment 2d

Non-response Data Collection Form for Medical Monitoring Project (MMP)

Non-Response Data Collection Form for

Medical Monitoring Project (MMP)

VERSION 1

Public reporting burden of this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. 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. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: CDC, Project Clearance Officer, 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0011). Do not send the completed form to this address.

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DEPARTMENT OF HEALTH AND HUMAN SERVICES

P

ublic Health Service

Centers for Disease Control and Prevention

Atlanta, GA 30333

MMP Non-response Data Collection Form

Instructions: Collect this information for all selected patients, who do not participate in the MMP interview. Obtain these data via HARS data extraction, from the facility, or from the patient during MMP recruitment. If possible, this information should also be obtained for all eligible patients seen during the PDP at each sampled facility, either via HARS data extraction or from each facility at the time the PDP patient list is provided.

Participant ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

Site ID Facility ID Respondent ID

Date Form Completed: ___ ___ / ___ ___ / ___ ___ ___ ___

m m d d y y y y

Data Sources:  1 HARS  2 Facility – included on patient list  3 Facility – after patient selected  4 Patient

(select all that apply)  8 Other (specify): __________________________________

Date of Birth: ___ ___ / ___ ___ / ___ ___ ___ ___

m m d d y y y y

First positive HIV

antibody test: Age: ___ ___ Date: ___ ___ / ___ ___ ___ ___

m m y y y y

First AIDS diagnosis: Age: ___ ___ Date: ___ ___ / ___ ___ ___ ___

m m y y y y

Sex:  1 Male  2 Female

Ethnicity:  1 Hispanic  2 Not Hispanic/Latino

(select one)  9 Unknown

Race:  1 American Indian/Alaska Native  5 White

(select all that apply)  2 Black or African American  9 Unknown

 3 Asian

 4 Native Hawaiian or Other Pacific Islander

Country of Birth:  1 US

 2 US Dependencies and Possessions (including Puerto Rico)

 8 Other (specify): __________________________________

Mode of HIV Exposure Yes No Unknown

Sex with male ……………………………………  1  0  9

Sex with female……………………………..……  1  0  9

Injected nonprescription drugs …………………  1  0  9

Received clotting factor …………………………  1  0  9

Heterosexual intravenous/injection drug user…  1  0  9

Bisexual male ……………………………………  1  0  9

Person with hemophilia/coagulation disorder…  1  0  9

Transfusion recipient with documented HIV …  1  0  9

Transplant recipient with documented HIV ..…  1  0  9

Person with AIDS or documented HIV,

risk not specified …………………………  1  0  9

Received transfusion of blood/blood

components (other than clotting factor) …  1  0  9

Received transplant of tissue/organs or

artificial insemination………………………  1  0  9

Worked in a health-care or clinical

laboratory setting………………………..…  1  0  9

First CD4 Test:

Count: ___, ___ ___ ___ Date: ___ ___ / ___ ___ ___ ___

m m y y y y

Percent: ___ ___ Date: ___ ___ / ___ ___ ___ ___

m m y y y y

Insurance (medical treatment primarily reimbursed by):

 1 Medicaid  2 Private insurance/HMO

 3 No coverage  4 Other public funding

 7 Clinical trial/  9 Unknown

government program