Medical Record Abstraction

Form Approved

OMB No. 0920-0840
Expiration Date 01/31/2013

Public reporting burden of this collection of information is estimated to average (15 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-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0840)

ATTACHMENT 2: MEDICAL RECORD ABSTRACTION FORM

Houston Department of Health and Human Services

Assessing the Accuracy of Self-Report of HIV Testing Behavior

Medical Chart Review Information

Patient I.D. _____________________________ Date of Abstraction ______________________

Patient Name: ___________________________________ Patient D.O.B. _________________

Facility I.D. ___________________________________________________________________

Person Completing Form: _______________________________________________________

Documented HIV Testing History:

Date	HIV Test Type	Test Result	Facility	City/State

Note: __________________________________________________________________________________

__________________________________________________________________________________