Form Viral Hepatitis In Viral Hepatitis In Viral Hepatitis Information Form

SAMHSA/CSAT’s Viral Hepatitis Information Form

SECTION A: SITE CHARACTERISTICS

Date of visit: ______

CLIENT ID: ______________

Provider ID: ____________

SITE ID: DB Consulting

Counselor ID:____________

Vaccine LOT NUMBER:___________________

SECTION B: DEMOGRAPHICS Previous Viral Hepatitis C Tests

Gender

Ethnicity

 No  Yes

 Male

 Hispanic

 Result was negative

 Female

 Non-Hispanic

 Result was positive

 Transgender

 Result was inconclusive

Race (Check all that apply)

 Result was unknown

Age

 Alaska Native

 18-24 yrs

 American Indian

Risk Factors

 25-34 yrs

 Asian

 HIV Positive  HCV Positive

 35-44 yrs

 Black/African American

 Liver Disease

 45-54 yrs

 Native Hawaiian/Other Pacific Islander

 Previous STD Diagnosis

 55-64 yrs

 White

 Intravenous Drug User

 65+ yrs

 Risky Sexual Behavior

 Other

SECTION C: SERVICE PROVIDED (Check all that apply)

 Viral Hepatitis A Vaccination

 Viral Hepatitis C Test

Vaccine Dose Dates

 Viral Hepatitis B Vaccination

 Viral Hepatitis Counseling

#1 #2

 Combined Viral Hepatitis A/B Vaccination

 Viral Hepatitis Educational Materials

#3

Section D: Viral Hepatitis C Testing

Viral Hepatitis C results

Did client receive results of test?

 Negative

 Yes

 Positive

 No, reason _____________________________________________

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

Re-test Result:

 Negative

 Positive

 Invalid

Test lot number (if available):______________ _____

Section E: TYPE OF REFERRAL SERVICES (check all that apply)

 Viral Hepatitis Testing  Viral Hepatitis Confirmatory Testing

 Viral Hepatitis Medical Care/ Evaluation/ Treatment

 Other Support Services

 General Medical Care

 Viral Hepatitis Prevention Counseling

 Reproductive health services/Prenatal care

 Mental Health Services

 Other (specify) __________________________________________ _____________________

 Other Hepatitis Prevention Services

 Tuberculosis Testing

 Case Management

 Family Counseling & Referral Services

 STD Screening and Treatment

 Comprehensive Risk Counseling & Services

 No Referral Services Received

Section F: Confirmatory Testing (if viral Hepatitis C test result is positive/reactive)

Confirmatory Test Conducted

Confirmatory test results

 Yes

 Negative

 Positive

 No, Reason

 Indeterminate

 Results Pending

Patient Refused Vaccine (specify)

Did client receive results of confirmatory test?

 Yes

 No, Reason ______________________________

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