Counseling, Testing and Referral Form

HIV Test Form
PART 1
Session Date
(mmddyyyy)

Printed Barcode

Client Date of Birth (MMDDYYYY)

State

Unique Agency ID Number

Intervention ID

County

*Site Type

L

Client Information

Form Approved
OMB No.: XXXX-XXXX
Exp. Date: XXXX

Intervention ID

Client ID
*See codes on reverse

L

Zip Code

Site ID

L

Race – Check all that apply

Ethnicity
Hispanic or Latino
Not Hispanic or Latino
Don’t know
Declined

Current Gender

American Ind./AK Native

Male
Female
Transgender – M2F
Transgender – F2M

Asian
Black/African American
Native HI/Pac. Islander
White
Don’t Know

Declined

Previous HIV Test? Self-Reported Result
Yes*
Positive
No
Negative
Don’t know
Prelim. Pos.
Declined
Indeterminate
Not asked
Don’t know
*If yes, provide
date of last test

Declined
Not asked

(MMYYYY)

Sample Date
(MMDDYYYY)

Tested anonymously
Tested anonymously
Tested anonymously
Tested confidentially
Tested confidentially
Tested confidentially
WORKER ID
WORKER ID
WORKER ID
Declined testing
Declined testing
Declined testing
If Agency: Type of Intervention from which Referred
Information about Agency Providing Service Linkage
Conventional
Conventional
Conventional
Rapid
Rapid
Rapid
Other
Other
Other

Test
Election:

Source

HIV TEST 1

Blood: finger stick
Blood: venipunture
Blood spot
Oral mucosal transudate
Urine

Blood: finger stick
Blood: venipunture
Blood spot
Oral mucosal transudate
Urine

Specimen
Type:

Test Result:

Positive/Reactive
Negative
Indeterminate

Result
Provided:

Yes

HIV TEST 2

Invalid
NAAT-pos
No result
No

HIV TEST 3

Blood: finger stick
Blood: venipunture
Blood spot
Oral mucosal transudate
Urine

L

HIV Test Information

Test
Technology:

Invalid
Positive/Reactive
Positive/Reactive
Negative
Negative
Housing Status
in the Past 3 months –
Sex Worker in NAAT-pos
the
Indeterminate
Check all that Indeterminate
apply
Past 3 months?No result
No

Yes

Invalid
NAAT-pos
No result

No

Yes

Date
Provided?
(MMDDYYYY)

Declined notification
Did not return/Could not locate
Obtained results from another agency
Client Sexual Risk Factors
Client declined to discuss risk factors
Client was not asked about risk factors
Client was asked, but no risk was identified

Check here if:

L

If client risk factor information was discussed, please record the
following:
Injection Drug Use (IDU)
In past 12 months has client had:
Vaginal or anal
sex

Oral Sex

if yes

With Male

Did client share drug
injection equipment?

With Female
Reserved for CDC Use
CDC
1
CDC
2

Has client used injection
drugs in past 12 months?

Declined notification
Did not return/Could not locate
Obtained results from another agency
Did client have vaginal or anal sex in
past 12 months:
...with person who is HIV positive?

Yes

No

...with person who is an IDU?

Declined notification
Did not return/Could not locate
Obtained results from another agency
Session Activity

During this visit, was a risk reduction plan
developed for the client?

Yes
No

Other Session Activities (see codes on reverse)

No

Yes
Yes ...with person who is MSM?
No
No
Yes
Yes ...without using a condom?
No
No
Yes

Local Use Fields
Local 4

Local 5

Other Sexual Factor(s)
Local 6

L

If results not
provided,
why?

Local 7

HIV Test Form
PART 2
Printed Barcode

Referrals

Local Use Fields

L

Invalid
NAAT-pos
No result

CDC requires the following information on positives.
Was client referred
to medical care?

Yes

L10

L11

L12

L13

L14

L15

L16

L17

L18

L19

L20

L21

If no, why?:

Did client attend
the first
appointment?

Yes
No
Don’t know

Client already in care
Client declined care

Was client referred to HIV
Prevention services?

Yes

No

Was client referred to PCRS?

Yes

No

If yes, in
prenatal
care?

L9

No

If yes:

If female, is client
pregnant?

L8

L

Positive/Reactive
Negative
Indeteminate

Client HIV test
result?

Yes
No

Don’t know
Declined

Not asked

Yes
No

Don’t know
Declined

Not asked

If no, was client referred for
prenatal care?

If yes, did client attend
first prenatal care
appointment?

Yes

L22

No
L23

Yes
No

Don’t know
L24

L25

NOTES
No more than 500 characters. PRINT ONLY

L26

L
Reserved for CDC Use
CDC 3

CDC 4

CDC 5

CDC 6

CDC 7

CDC 8

Public reporting burden of this collection of information is estimated to average 8 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/ATSDR Reports Clearance Officer,
1600 Clifton Road NE, MS D-79, Atlanta, Georgia 30333; ATTN: PRA 0920-XXXX.

L

L