Form HIV-AIAN/RHTI Data HIV-AIAN/RHTI Data HIV-AIAN/RHTI Data Collection Form

Minority AIDS Initiative for Collaboration for Prevention and Treatment Improvement for AIANs at Risk for Substance Use and HIV/AID, (MIA) Rapid HIV Testing Clinical Information Form

RHTI Data Collection Tool AI-AN v4 (3)

HIV/AID Rapid Testing Clinical Information Form

OMB: 0930-0295

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0930-0295 can be found here:

Document [doc]

Download: doc | pdf

SAMHSA MAI Rapid HIV Testing Clinical Information Form

----------------------------------------------------------------------------------------------------------------------------------------------------------------------

SECTION A: SITE CHARACTERISTICS

Provider ID: ____________

SAMHSA CLIENT ID:

_________________

(Bar code)

Date of visit_______________________

Site ID: ________________

Site Type:

 Tribal Clinic

 Urban Indian Health Clinic

 IHS Health Clinic

 Other (specify)________________________

RAPID TEST KIT LOT NUMBER:___________________

SECTION B: DEMOGRAPHICS

1. Gender

3. Ethnicity

5. Previous HIV Test

 Male

 Hispanic

 No

 Female

 Non-Hispanic

 Yes

 Transgender

 Result was negative

4. Race (Check all that apply)

 Result was positive

2. Age

 Black/African American

 Result was inconclusive

 <18 years

 Asian

 Result was unknown

 18-24 yrs

 Native Hawaiian/Other Pacific Islander

 25-34 yrs

 Alaska Native

 35-44 yrs

 White

 45-54 yrs

 American Indian

 55-64 yrs

 Other (specify)_______________________

 65+ yrs

SECTION C: REASON FOR TEST: __________________________________________________________

SECTION D: WHAT BEHAVIORS DO YOU ENGAGE IN THAT PUT YOU AT RISK? (Check all that apply)

1. During the past 30 days have you:

 had unprotected sex with male

 injected drugs

 exchanged sex for drugs/money

 had unprotected sex with female

 used illegal drugs

 had unprotected sex with transgender

 used any alcohol

2. The client:

 reports no known risk factors

 refuses to report risk factors

Section E: Rapid HIV Testing

1. Rapid test results

2. Did client receive results of rapid test?

 Negative/Non-reactive

 Yes

 Positive/Reactive

 No, reason _____________________________________________

 Invalid (Repeat test using a new test kit.)

Retest Result:

 Negative/

Non-reactive

 Positive/

Reactive

 Invalid

Rapid test kit lot number (client retested):_________________

Section F: TYPE OF SERVICES PROVIDED (Check all that apply)

 HIV Prevention Counseling

 HIV Pre-Test Counseling

 HIV Post-Test Counseling

 Linked to care/treatment after confirmatory testing

Section G: Confirmatory Testing (if rapid test result is positive/reactive)

1. Confirmatory test conducted

3. Confirmatory test results

 Yes

 Negative

 Yes: Client now wants a confirmatory test after initial refusal.

 Positive

 No, reason _______________________________________

 Indeterminate

__________________________________________________

 Results pending

2. Type of confirmatory test

4. Did client receive results of confirmatory test?

 Blood (plasma, serum, or blood spot)

 Yes

 Oral

 No, reason ______________________________

 Urine

White: Complete with Rapid Test (Sections A thru F)

RETURN TO: WESTAT; 1700 Research Blvd.; Room RB 4247, Rockville, MD 20850; Attn: May Yamate

Project Number: 7853.05.01.14

SAMHSA MAI HIV Rapid Testing Clinical Information Form

----------------------------------------------------------------------------------------------------------------------------------------------------------------------

SECTION A: SITE CHARACTERISTICS

Provider ID: ____________

SAMHSA CLIENT ID:

_________________

(Bar code)

Date of visit_______________________

Site ID: ________________

Site Type:

 Tribal Clinic

 Urban Indian Health Clinic

 IHS Health Clinic

 Other (specify)________________________

RAPID TEST KIT LOT NUMBER:___________________

SECTION B: DEMOGRAPHICS

1. Gender

3. Ethnicity

5. Previous HIV Test

 Male

 Hispanic

 No

 Female

 Non-Hispanic

 Yes

 Transgender

 Result was negative

4. Race (Check all that apply)

 Result was positive

2. Age

 Black/African American

 Result was inconclusive

 <18 years

 Asian

 Result was unknown

 18-24 yrs

 Native Hawaiian/Other Pacific Islander

 25-34 yrs

 Alaska Native

 35-44 yrs

 White

 45-54 yrs

 American Indian

 55-64 yrs

 Other (specify)_______________________

 65+ yrs

SECTION C: REASON FOR TEST: __________________________________________________________

SECTION D: WHAT BEHAVIORS DO YOU ENGAGE IN THAT PUT YOU AT RISK? (Check all that apply)

1. During the past 30 days have you:

 had unprotected sex with male

 injected drugs

 exchanged sex for drugs/money

 had unprotected sex with female

 used illegal drugs

 had unprotected sex with transgender

 used any alcohol

2. The client:

 reports no known risk factors

 refuses to report risk factors

Section E: Rapid HIV Testing

1. Rapid test results

2. Did client receive results of rapid test?

 Negative/Non-reactive

 Yes

 Positive/Reactive

 No, reason _____________________________________________

 Invalid (Repeat test using a new test kit.)

Retest Result:

 Negative/

Non-reactive

 Positive/

Reactive

 Invalid

Rapid test kit lot number (client retested):_________________

Section F: TYPE OF SERVICES PROVIDED (Check all that apply)

 HIV Prevention Counseling

 HIV Pre-Test Counseling

 HIV Post-Test Counseling

 Linked to care/treatment after confirmatory testing

Section G: Confirmatory Testing (if rapid test result is positive/reactive)

1. Confirmatory test conducted

3. Confirmatory test results

 Yes

 Negative

 Yes: Client now wants a confirmatory test after initial refusal.

 Positive

 No, reason _______________________________________

 Indeterminate

__________________________________________________

 Results pending

2. Type of confirmatory test

4. Did client receive results of confirmatory test?

 Blood (plasma, serum, or blood spot)

 Yes

 Oral

 No, reason ______________________________

 Urine

Yellow: Complete for Confirmatory Test (Complete Section G)

RETURN TO: WESTAT; 1700 Research Blvd.; Room RB 4247, Rockville, MD 20850; Attn: May Yamate

Project Number: 7853.05.01.14

SAMHSA MAI Rapid HIV Testing Clinical Information Form

----------------------------------------------------------------------------------------------------------------------------------------------------------------------

SECTION A: SITE CHARACTERISTICS

Provider ID: ____________

SAMHSA CLIENT ID:

_________________

(Bar code)

Date of visit_______________________

Site ID: ________________

Site Type:

 Tribal Clinic

 Urban Indian Health Clinic

 IHS Health Clinic

 Other (specify)________________________

RAPID TEST KIT LOT NUMBER:___________________

SECTION B: DEMOGRAPHICS

1. Gender

3. Ethnicity

5. Previous HIV Test

 Male

 Hispanic

 No

 Female

 Non-Hispanic

 Yes

 Transgender

 Result was negative

4. Race (Check all that apply)

 Result was positive

2. Age

 Black/African American

 Result was inconclusive

 <18 years

 Asian

 Result was unknown

 18-24 yrs

 Native Hawaiian/Other Pacific Islander

 25-34 yrs

 Alaska Native

 35-44 yrs

 White

 45-54 yrs

 American Indian

 55-64 yrs

 Other (specify)_______________________

 65+ yrs

SECTION C: REASON FOR TEST: __________________________________________________________

SECTION D: WHAT BEHAVIORS DO YOU ENGAGE IN THAT PUT YOU AT RISK? (Check all that apply)

1. During the past 30 days have you:

 had unprotected sex with male

 injected drugs

 exchanged sex for drugs/money

 had unprotected sex with female

 used illegal drugs

 had unprotected sex with transgender

 used any alcohol

2. The client:

 reports no known risk factors

 refuses to report risk factors

Section E: Rapid HIV Testing

1. Rapid test results

2. Did client receive results of rapid test?

 Negative/Non-reactive

 Yes

 Positive/Reactive

 No, reason _____________________________________________

 Invalid (Repeat test using a new test kit.)

Retest Result:

 Negative/

Non-reactive

 Positive/

Reactive

 Invalid

Rapid test kit lot number (client retested):_________________

Section F: TYPE OF SERVICES PROVIDED (Check all that apply)

 HIV Prevention Counseling

 HIV Pre-Test Counseling

 HIV Post-Test Counseling

 Linked to care/treatment after confirmatory testing

Section G: Confirmatory Testing (if rapid test result is positive/reactive)

1. Confirmatory test conducted

3. Confirmatory test results

 Yes

 Negative

 Yes: Client now wants a confirmatory test after initial refusal.

 Positive

 No, reason _______________________________________

 Indeterminate

__________________________________________________

 Results pending

2. Type of confirmatory test

4. Did client receive results of confirmatory test?

 Blood (plasma, serum, or blood spot)

 Yes

 Oral

 No, reason ______________________________

 Urine

Pink: Keep for your records

Page 4 of 3

File Type	application/msword
File Title	SAMHSA’S Rapid HIV Testing Initiative
Author	May Yamate
Last Modified By	USER
File Modified	2008-07-21
File Created	2008-07-21