HIV test scan form - page 1

GENERAL INSTRUCTIONS FOR COMPLETING THE HIV TEST FORM
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This form is designed to be read by an Optical Character Recognition (OCR) scanner. The legibility of this form depends on
the quality of the hand-written and selected information.
Carefully separate the sheets at the perforations. If the form tears, it may not be readable by the scanner or operator.
Each part has a top sheet and a bottom carbonless copy. The top copy (white) is the only sheet that should be scanned. The
bottom copy (yellow) should NOT be scanned; rather it should be used for record keeping purposes.
DO NOT use red ink. Blue or black ink is preferred.
DO NOT fold, staple, wrinkle or tear form(s).
DO NOT USE WHITE OUT. White out sometimes will cause a mis-read by the scanning software.
DO NOT mark on the bar codes of the Form ID numbers. Marking on the Form ID numbers (barcode) may cause the wrong
number to be scanned.
DO NOT make any stray marks on the form(s), particularly in the fields where answers will appear.
Part 1 is the only form with a pre-printed code. You must attach a form identification sticker (barcode) located on the back
of the carbonless copy (yellow) to Part 2 and/or Part 3 in order to link a client’s information.
o Part 1 should be used for all testing events
o Part 2 should be used to record referral data on confirmed HIV positive clients
o Part 3 is used by jurisdictions funded to collect HIV Incidence data.

RESPONSE FORMATS
There are three different response formats on the form that you will use to record data: (1) text boxes, (2) check boxes, and (3)
radio buttons. Instructions for each one of these formats are listed below.
Text boxes
Text boxes are used to record handwritten information (e.g., codes, dates). When writing letters or numbers in the boxes:
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use all capital letters and write neatly in your best penmanship. DO NOT use cursive.
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put only 1 letter or number per box and DO NOT have any part of the letter or number touch the edges of the box.
Here are examples of how to write letters and numbers:
LETTERS

NUMBERS

Check boxes
Check boxes are used to select all options that apply. For example, check boxes are used to record information about “Race.”
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use an “X” instead of a check mark because the tail of the check mark might run over into another box.
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keep the “X” within the edges of the box.
Radio buttons
Radio buttons are ovals used to select only one option from among two or more options. For example, radio buttons are used to select
“Current Gender.” When selecting an option using a radio button:
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fill in the oval completely.
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DO NOT mark over area of the oval.

HIV TEST FORM

Code 128

PART 1

0000000000

Form Approved: OMB No. 0920-0696, Exp. Date: 08/31/2010

Agency

Session Date (MMDDYYYY)

Unique Agency ID Number

Intervention ID
MMDD

Site ID

.

Site Type
(See codes on reverse)

Client ID

L

Hispanic or Latino
Not Hispanic or Latino
Don’t know
Declined

Current Gender
Male
Female
Transgender – M2F
Transgender – F2M

Black/African American
Native HI/Pac. Islander

L

White
Don’t know

State

Zip Code

County

Previous HIV Test?
Self-Reported Result
Yes
Positive
Indeterminate
No
Don’t know
Negative
Don’t know
Declined
Prelim. Pos.
Declined
Not asked
Not asked Provide date of last test (MMYYYY)

L

Race – Check all that apply
American Ind./AK Native
Asian

Ethnicity

Client

Date of Birth (MMDDYYYY)

Intervention
ID
Site Zip Code

Declined

Sample Date
(MMDDYYYY)

Source
Test
Election

Tested anonymously
Tested confidentially
Declined testing

Tested anonymously
Tested confidentially
Declined testing

Tested anonymously
Tested confidentially
Declined testing

Test
Technology

Conventional
Rapid
Other

Conventional
Rapid
Other

Conventional
Rapid
Other

Specimen
Type

Blood: finger stick
Blood: venipuncture
Blood spot
Oral mucosal transudate
Urine

Test Result

Positive/Reactive
NAAT-pos
Negative

Result
Provided

HIV TEST 1

Yes

HIV TEST 2

Blood: finger stick
Blood: venipuncture
Blood spot
Oral mucosal transudate
Urine
Indeterminate
Invalid
No result

No

Positive/Reactive
NAAT-pos
Negative
Yes

HIV TEST 3

Blood: finger stick
Blood: venipuncture
Blood spot
Oral mucosal transudate
Urine
Housing Status in the Past 3 months –
Check all that apply
Indeterminate
Indeterminate
Positive/Reactive
Invalid
Invalid
NAAT-pos
No result
No result
Negative

L

HIV Test Information

Worker ID

Yes

No

No

If results not
provided,
why?

Declined notification
Did not return/Could not locate
Obtained results from another agency

Declined notification
Did not return/Could not locate
Obtained results from another agency

Declined notification
Did not return/Could not locate
Obtained results from another agency

If rapid
reactive, did
client provide
confirmatory
sample?

Yes
Client declined confirmatory test
Did not return/Could not locate
Referred to another agency
Other

Yes
Client declined confirmatory test
Did not return/Could not locate
Referred to another agency
Other

Yes
Client declined confirmatory test
Did not return/Could not locate
Referred to another agency
Other

Choose one if:

Client was not asked about risk factors

Client was asked, but no risk was identified

Client declined to discuss risk factors

If client risk factor information was discussed, please mark all that apply:
...without using a condom?
In past 12 months has client had:
Injection Drug Use (IDU)
Vaginal or Anal Sex

L

...with person who is an IDU?

if marked

Did client share drug injection
equipment?

...with person who is HIV positive?

Session Activity

.

(see codes on reverse)

CDC Use Fields

Local Use Fields

During this visit, was a risk reduction plan developed
Yes
for the client?
Other Session Activities (see codes on reverse)

.

No

Other Risk Factor(s)

Has client used injection drugs in
past 12 months?

...with person who is MSM? (Female
Only)

With Male
With Female

Oral Sex

L

Risk Factors

Date Provided
(MMDDYYYY)

L1

L2

C1
C2

Public reporting burden of this collection of information is estimated to average 8 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-79, Atlanta, Georgia 30333; ATTN: PRA 0920-0696.
CDC 50.135a (E), 10/2007
WHITE COPY = Scan
YELLOW COPY = Record Keeping

HIV TEST FORM

Code 128

PART 1

0000000000

Form Approved: OMB No. 0920-0696, Exp. Date: 08/31/2010

Agency

Session Date (MMDDYYYY)

Unique Agency ID Number

Intervention ID
MMDD

Site ID

.

Site Type
(See codes on reverse)

Client ID

L

Hispanic or Latino
Not Hispanic or Latino
Don’t know
Declined

Current Gender
Male
Female
Transgender – M2F
Transgender – F2M

Black/African American
Native HI/Pac. Islander

L

White
Don’t know

State

Zip Code

County

Previous HIV Test?
Self-Reported Result
Yes
Positive
Indeterminate
No
Don’t know
Negative
Don’t know
Declined
Prelim. Pos.
Declined
Not asked
Not asked Provide date of last test (MMYYYY)

L

Race – Check all that apply
American Ind./AK Native
Asian

Ethnicity

Client

Date of Birth (MMDDYYYY)

Intervention
ID
Site Zip Code

Declined

Sample Date
(MMDDYYYY)

Source
Test
Election

Tested anonymously
Tested confidentially
Declined testing

Tested anonymously
Tested confidentially
Declined testing

Tested anonymously
Tested confidentially
Declined testing

Test
Technology

Conventional
Rapid
Other

Conventional
Rapid
Other

Conventional
Rapid
Other

Specimen
Type

Blood: finger stick
Blood: venipuncture
Blood spot
Oral mucosal transudate
Urine

Test Result

Positive/Reactive
NAAT-pos
Negative

Result
Provided

HIV TEST 1

Yes

HIV TEST 2

Blood: finger stick
Blood: venipuncture
Blood spot
Oral mucosal transudate
Urine
Indeterminate
Invalid
No result

No

Positive/Reactive
NAAT-pos
Negative
Yes

HIV TEST 3

Blood: finger stick
Blood: venipuncture
Blood spot
Oral mucosal transudate
Urine
Housing Status in the Past 3 months –
Check all that apply
Indeterminate
Indeterminate
Positive/Reactive
Invalid
Invalid
NAAT-pos
No result
No result
Negative

L

HIV Test Information

Worker ID

Yes

No

No

If results not
provided,
why?

Declined notification
Did not return/Could not locate
Obtained results from another agency

Declined notification
Did not return/Could not locate
Obtained results from another agency

Declined notification
Did not return/Could not locate
Obtained results from another agency

If rapid
reactive, did
client provide
confirmatory
sample?

Yes
Client declined confirmatory test
Did not return/Could not locate
Referred to another agency
Other

Yes
Client declined confirmatory test
Did not return/Could not locate
Referred to another agency
Other

Yes
Client declined confirmatory test
Did not return/Could not locate
Referred to another agency
Other

Choose one if:

Client was not asked about risk factors

Client was asked, but no risk was identified

Client declined to discuss risk factors

If client risk factor information was discussed, please mark all that apply:
...without using a condom?
In past 12 months has client had:
Injection Drug Use (IDU)
Vaginal or Anal Sex

L

...with person who is an IDU?

if marked

Did client share drug injection
equipment?

...with person who is HIV positive?

Session Activity

.

(see codes on reverse)

CDC Use Fields

Local Use Fields

During this visit, was a risk reduction plan developed
Yes
for the client?
Other Session Activities (see codes on reverse)

.

No

Other Risk Factor(s)

Has client used injection drugs in
past 12 months?

...with person who is MSM? (Female
Only)

With Male
With Female

Oral Sex

L

Risk Factors

Date Provided
(MMDDYYYY)

L1

L2

C1
C2

Public reporting burden of this collection of information is estimated to average 8 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-79, Atlanta, Georgia 30333; ATTN: PRA 0920-0696.
CDC 50.135a (E), 10/2007
WHITE COPY = Scan
YELLOW COPY = Record Keeping

Client Identifying Data (Optional)
Name: _______________________________________________________________________________________________________________________
Address:______________________________________________________________________________________________________________________
Phone: ___________________________________ Other: ____________________________________________________________________________
Codes for Site Type
F01
Inpatient Facility
F01.01
Inpatient Hospital
F01.50
Inpatient- Drug / Alcohol Treatment
F01.88
In patient Facility- Other
F01.99
Inpatient Facility- Unknown
F02
Outpatient facility
F02.03
Outpatient- Private Medical Practice
F02.04
Outpatient- HIV Specialty Clinic
F02.10
Outpatient- Prenatal/ OBGYN Clinic
F02.12
Outpatient- TB Clinic
F02.19
Outpatient- Drug / Alcohol Treatment Clinic
F02.20
Outpatient- Family Planning
F02.30
Outpatient- Community Mental Health
F02.51
Outpatient- Community Health Clinic
F02.58
Outpatient- School/University Clinic
F02.60
Outpatient- Health Department/Public Health Clinic
F02.61
Outpatient- Health Department/Public Health Clinic-HIV
F02.62
Outpatient- Health Department/Public Health Clinic-STD
F02.88
Outpatient Facility- Other
Codes for Other Risk factor(s)
01
Exchange sex for drugs/money/or something they need
02
While intoxicated and/or high on drugs
05
With person of unknown HIV status
06
With person who exchanges sex for drugs/money
08
With anonymous partner
09
With person who has hemophilia or transfusion/transplant recipient
11
Sex with transgender
Codes for Other Session Activities
01.00
Not Collected
03.00
HIV Testing
04.00
Referral
05.00
Personalized Risk assessment
06.00
Elicit Partners
07.00
Notification of exposure
08.01
Information – HIV/AIDS transmission
08.02
Information-Abstinence/postpone sexual activity
08.03
Information-Other sexually transmitted diseases
08.04
Information-Viral hepatitis
08.05
Information – Availability of HIV/STD counseling and testing
08.06
Information-Availability of partner notification and referral
services
08.07
Information – Living with HIV/AIDS
08.08
Information – Availability of social services
08.09
Information – Availability of medical services
08.10
Information – Sexual risk reduction
08.11
Information – IDU risk reduction
08.12
Information – IDU risk free behavior
08.13
Information – Condom/barrier use
08.14
Information – Negotiation / Communication
08.15
Information – Decision making
08.16
Information – Disclosure of HIV status
08.17
Information – Providing prevention services
08.18
Information – HIV testing
08.19
Information – Partner notification
08.20
Information – HIV medication therapy adherence
08.21
Information – Alcohol and drug use prevention
08.22
Information – Sexual health
08.23
Information – TB testing
08.66
Information – Other
09.01
Demonstration – Condom/barrier use
09.02
Demonstration – IDU risk reduction
09.03
Demonstration – Negotiation / Communication
09.04
Demonstration – Decision making
09.05
Demonstration – Disclosure of HIV status
09.06
Demonstration – Providing prevention services
09.07
Demonstration – Partner notification
09.88
Demonstration – Other
10.01
Practice – Condom/barrier use
10.02
Practice – IDU risk reduction
10.03
Practice – Negotiation / Communication
10.04
Practice – Decision making
10.05
Practice – Disclosure of HIV status
10.06
Practice – Providing prevention services

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F02.99
F03
F04.01
F04.05
F06
F06.01
F06.02
F06.03
F06.04
F06.05
F06.06
F06.07
F06.08
F06.09
F06.12
F06.10
F06.88
F07
F88

Outpatient Facility- Unknown
Emergency Room
Blood Bank, Plasma Center
HIV Counseling and Testing Site
Community Setting
Community Setting – AIDS Service Organization – non clinical
Community Setting – School/Education Facility
Community Setting – Church/Mosque/Synagogue/Temple
Community Setting – Shelter/Transitional housing
Community Setting – Commercial
Community Setting – Residential
Community Setting – Bar/Club/Adult Entertainment
Community Setting – Public Area
Community Setting – Workplace
Individual Residence
Community Setting – Community Center
Community Setting – Other
Correctional Facility
Facility – Other

10.07
10.88
11.01
11.02
11.03
11.04
11.05
11.06
11.07
11.08
11.09
11.10
11.11
11.12
11.13
11.14

Practice – Partner notification
Practice – Other
Discussion – Sexual risk reduction
Discussion – IDU risk reduction
Discussion – HIV testing
Discussion – Other sexually transmitted diseases
Discussion – Disclosure of HIV status
Discussion – Partner notification
Discussion – HIV medication therapy adherence
Discussion – Abstinence/postpone sexual activity
Discussion – IDU risk free behavior
Discussion – HIV/AIDS transmission
Discussion – Viral hepatitis
Discussion – Living with HIV/AIDS
Discussion – Availability of HIV/AIDS counseling testing
Discussion – Availability of partner notification and referral
services
Discussion – Availability of social services
Discussion – Availability of medical services
Discussion – Condom/barrier use
Discussion – Negotiation / Communication
Discussion – Decision making
Discussion – Providing prevention services
Discussion – Alcohol and drug use prevention
Discussion – Sexual health
Discussion – TB testing
Discussion – Stage Based Encounter
Discussion – Other
Other testing – Pregnancy
Other testing – STD
Other testing – Viral hepatitis
Other testing – TB
Distribution – Male condoms
Distribution – Female condoms
Distribution – Safe sex kits
Distribution – Safer injection / bleach kits
Distribution – Lubricants
Distribution – Education materials
Distribution – Referral lists
Distribution – Role model stories
Distribution – Dental DAMS
Distribution – Other
Post-intervention follow up
Post-intervention booster session
HIV Testing History Survey
Other

11.15
11.16
11.17
11.18
11.19
11.20
11.21
11.22
11.23
11.24
11.88
12.01
12.02
12.03
12.04
13.01
13.02
13.03
13.04
13.05
13.06
13.07
13.08
13.09
13.88
14.01
14.02
15.00
89

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