Reverse Side of CTR Form with Codes

Back of HIV Test Form

Client Identifying Data (Optional)
Name: _______________________________________________________________________________________________
Address: _____________________________________________________________________________________________
Phone: ________________________________ Other: ________________________________________________________

Codes for Other Risk Factor(s)
01 Exchange sex for drugs/money/or something they need
02 While intoxicated and/or high on drugs
05 With person of unknown HIV status
06 With person who exchanges sex for drugs/money
08 With anonymous partner
09 With person who has hemophilia or transfusion/transplant recipient

Codes for Session Activities
01 HIV testing
02 Referral
03 Personalized risk assessment
04 Elicit partners
05 Notification of exposure
06 Information-HIV/AIDS transmission
07 Information-Abstinence/postpone sexual activity
08 Information-Other sexually transmitted diseases
09 Information-Viral hepatitis
10 Information-Availability of HIV/STD counseling and testing
11 Information-Availability of partner notification and referral services
12 Information-Living with HIV/AIDS
13 Information-Availability of social services
14 Information-Availability of medical services
15 Information-Sexual risk reduction
16 Information-IDU risk reduction
17 Information-IDU risk free behavior
18 Information- Condom/barrier use
19 Information-Negotiation/Communication
20 Information-Decision making
21 Information-Disclosure of HIV status
22 Information-Providing prevention services
23 Information-HIV testing
24 Information-Partner notification
25 Information-HIV medication therapy adherence
26 Information-Alcohol and drug use prevention
27 Information-Sexual health
28 Information- TB testing
29 Information-Other
30 Demonstration-Condom/barrier use
31 Demonstration-IDU risk reduction
32 Demonstration-Negotiation/Communication
33 Demonstration-Decision making
34 Demonstration-Disclosure of HIV status
35 Demonstration-Providing prevention services
36 Demonstration-Partner notification
37 Demonstration-Other
38 Practice-Condom/barrier use
39 Practice-IDU risk reduction
40 Practice-Negotiation/Communication
41 Practice-Decision making
42 Practice-Disclosure of HIV status
43 Practice-Providing prevention services

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Practice-Partner notification
Practice-Other
Discussion-Sexual risk reduction
Discussion-IDU risk reduction
Discussion-HIV testing
Discussion-Other sexually transmitted diseases
Discussion-Disclosure of HIV status
Discussion-Partner notification
Discussion-HIV medication therapy adherence
Discussion-Abstinence/postpone sexual activity
Discussion-IDU risk free behavior
Discussion-HIV/AIS transmission
Discussion-Viral hepatitis
Discussion- Living with HIV/AIDS
Discussion- Availability of HIV/AIDS counseling and testing
Discussion-Availability of partner notification and referral services
Discussion-Availability of social services
Discussion-Availability of medical services
Discussion- Condom/barrier use
Discussion-Negotiation/Communication
Discussion-Decision making
Discussion-Providing prevention services
Discussion-Alcohol and drug use prevention
Discussion-Sexual health
Discussion- TB testing
Discussion -Other
Other testing-Pregnancy
Other testing-STD
Other testing-Viral hepatitis
Other testing- TB
Distribution-Male condoms
Distribution-Female condoms
Distribution-Safe sex kits
Distribution-Safer injection/bleach kits
Distribution-Lubricants
Distribution-Education materials
Distribution-Referral lists
Distribution-Role model stories
Distribution-Other
Post-intervention follow up
Post-intervention booster session
HIV Testing History Survey
Other