HCV Testing - Screener

Form Approved

OMB No. 0920-0840

Expiration Date 01/13/2013

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

Attachment 5b. Community Health Awareness Group Screening and Contact 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)

Date ____________ Client ID __________________ Staff ID ___________

COMMUNITY HEALTH AWARENESS GROUP HCV PRE-COUNSELING RISK ASSESSMENT

This form is designed to learn more about things people do that could put them at risk for the Hepatitis C Virus (HCV), HIV and other blood borne diseases. The questions are personal but we ask that you answer them as honestly as you can. The testing counselor will go over this form with you. Please check only one item in each category unless otherwise noted. Do not put your name on the form.

DEMOGRAPHICS

Zip code ____________ County_____________ State ____ Age ______ Birthdate ____________

Gender: Male Female Transgender: M F F M

Females only: Are you pregnant now? Yes No If yes, are you in prenatal care? Yes No

Education: 8^th grade/less Some high school (HS) HS graduate/GED

Some college Bachelors degree Post-Graduate

Race: American Indian or Alaskan Native Asian or Pacific Islander Black White

Ethnicity: Hispanic Origin Not of Hispanic Origin

Martial Status: Single Married Divorced/Separated Widowed Living Together

Hepatitis C Virus (HCV) TESTING HISTORY

Have you ever been tested for Hepatitis C? Yes No

If tested, what were your results? Negative Positive Unknown

When were you tested? ________________________ Where were you tested?____________________________

HIV COUNSELING AND TESTING HISTORY

Have you ever been tested for HIV (AIDS virus)? Yes No

If tested, what were your results? Negative Positive Unknown

When were you tested? ________________________ Where were you tested?____________________________

DRUG USE FOR THE LAST 3 MONTHS (90 DAYS) ONLY

The following questions are about your drug use in the last 3 months. If you have not used drugs, please check Not Applicable (NA).

Which of the following have you used in the last 3 months? (check all that apply)

Crack/Cocaine Heroin Marijuana Methamphetamine Methadone PCP Acid

Speed Crystal Ice Other ________________________________ NA

Have you used a needle to inject drugs? Yes No NA

If yes, did you share needles? Yes No

If yes, what did you use to clean your needles? (Check all that apply)

Hot water Alcohol Bleach Water & Bleach Other_________________

SEXUAL BEHAVIOR FOR THE LAST 3 MONTHS (90 DAYS) ONLY

How many sex partners have you had in the last 3 months?___________

Have your partners been (check all that apply): Male Female Transgender

How often do you or your partner(s) use condoms? Always Usually Sometimes Never

Did you give sex for drugs or money? Yes No

In the last 3 months have you had sex with?

Someone who shoots drugs (IDU) Yes No

Anonymous partner Yes No

Person you met on the Internet Yes No

Man who had sex with a man Yes No

Person with HIV/AIDS Yes No

Person who has a sexually transmitted disease (STD) Yes No

Person who gave sex for drugs or money Yes No

Have you had sex while using alcohol or any other drugs? Yes No

SEXUALLY TRANSMITTED & BLOODBORNE INFECTIONS IN LAST 3 MONTHS

Have you experienced any of the following? (Check all that apply)

Chlamydia Genital Warts (HPV) Gonorrhea Hepatitis B Herpes

Syphilis Other Sexually Transmitted Infection (STI)_____________________

Are you a hemophiliac or had a blood transfusion? Yes No

How did you hear about CHAG’s Hepatitis C counseling and testing service?

Agency Referral Referred by Partner (Sexual or Drug) Referred by family or friend

Self Referral Presentation/Public Announcement Other ________________________________

What is your reason for wanting to be tested for Hepatitis C (HCV) today?

Concerned might have been exposed to HCV Get tested routinely and it was time to test again

Just checking to make sure I am HCV negative Required by insurance, military, court order or other

Other ___________________________________________________

How high do you consider your risk for HCV to be? High Medium Low

A counselor will review your answers with you. Thank you for completion of the form.

File:CHAGPreCRiskForm (draft February 2011)