HCV Testing - Denver screener

Form Approved

OMB No. 0920-0840

Expiration: 01/31/2013

“Demonstration Project of HCV Rapid Tests in HIV Testing Settings”

Attachment 5a. Denver Public Health/Alert Health, Inc. Screening and Contact Form

CDPHE Hepatitis C Client Demographic Form

Public reporting burden of this collection of information is estimated to average 5 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 (OMB 0920-0840)

Denver Public Health 605 Bannock, Denver, CO 80204

Demographics 1 only HCV positive clients—Demographics 2 all clients

DEMOGRAPHICS 1: COMPLETE FOR HCV+ CLIENTS ONLY

____________________________________________ __________________ ___________ ____

Last Name First Name MI

____________________________________________ (____)______-___________

Client Street Address Telephone

DEMOGRAPHICS 2: COMPLETE FOR ALL CLIENTS

________________________________ _______________ _________ ______________________________

City of Residence State of Residence ZIP County of Residence

Birth date: ____/_____/______ _____

MM DD YY Age

Sex:  Male Client ethnicity (mark only one): Client race (mark all that apply

 Female  Hispanic or Latino  American Indian or Alaska Native

 Not Hispanic or Latino  Asian

 Refused to answer  Black or African American

 Native Hawaiian or Other Pacific Islander

 White

 Refused to answer

TESTING RISK FACTORS Yes No

Injection drug use? 5 5

Recipient of blood, blood products, or tissue prior to 1992? 5 5

If yes, year_______________

Recipient of any of the above at anytime outside US? 5 5

If Yes, Country, Year __________________________________

Have ever been on hemodialysis? 5 5

Sexual partner of an HCV positive person? 5 5

Needle sharing partner of an HCV positive person? 5 5

Did any of these risks occur in the last 6 months? 5 5

If yes, please discuss retesting with client*

Comments (other risks, concerns, etc): _______________________________________________

HCV TESTING HISTORY:

Self-reported testing history:

 Never tested before

 Yes, tested previously

 Client refused to answer

Date last HCV test _____/________

Self-reported HCV status at time of visit:

 Positive

—if positive client is NOT a candidate for testing under this program┼┼. Provide information packet)

 Negative  Client refused to answer

 Unknown  Indeterminate

CURRENT HCV TEST:

Collection Date:

Test Type: Results:

_____/_____/_____  Finger stick HCV EIA:  Reactive S/Co: ______

MM DD YY  Blood draw  Non-Reactive  Indeterminate

RIBA:  Positive  Negative

 Inadequate/indeterminate

CLIENT INFORMED OF RESULTS?  Yes

If no, reason?  Unable to locate  Client refused

Other:_________________________________

TO BE COMPLETED BY CDPHE: New Diagnosis?  Yes  No

FEMALE CLIENTS ONLY

Is the client Pregnant?

 Yes

 No

If yes, is the client in prenatal care?

 Yes

 No

If pregnant, please discuss perinatal transmission┼

* HCV antibodies can be detected in >97% of persons by 6 months after the exposure; the average time from exposure to seroconversion is 8 to 9 weeks (CDC).

┼Perinatal transmission occurs in <5% of live births, in HIV/HCV coinfected mothers perinatal transmission of HCV may be as high as 19% (CDC). Infants may be tested for HCV antibodies at 18 months or later. If desired, HCV RNA testing may be performed at first well child visit. There is a high rate of viral clearance in the first year of life (AASLD).

┼┼HCV antibodies persist even in clients who clear the virus. If the client has a previous positive antibody response additional antibody testing will not yield any new information. Clients should be referred for medical follow up and more advanced testing.