HIV test form - Pacific Islands

OMB # 0920-0696 Exp. Date:08/31/2010

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Session Date
m

m

d

d

Jurisdiction
y

Site Type ID

Client ID

Client Date of Birth

y

m

Current Residence

Gender

Island

(Specify) ____________________________

Village

(Specify) ____________________________

FSM



Yap State



Chuuk State



Kosrae State



Pohnpei State

Other

Worker ID

Pacific Islands HIV Test Form






Male
Female
Transgender – M to F
Transgender – F to M








Ethnicity





(Specify) ____________________________

Hispanic or Latino
Not Hispanic or Latino
Don’t know

m

d

d

y

y

y

y

Race
Check all that apply
American Ind/AK Native
Asian
Black/African American
Native HI/Pac. Islander
White
Don’t know
Specify
nationality ___________________________

Client Risk Factors
1. In the past 12 months, have you had sex
with a male (vaginal or anal)?
 Yes----------- No. of partners





No



No

 No

Previous HIV Test?







 Yes
 No

4. In the past 12 months, did you
engage in any other behaviors or
activities that you feel increased
your risk for HIV?

… with a female (vaginal or anal)?
 Yes----------- No. of partners



 Yes

3. In the past 12 months,
have you injected any
drugs?

Yes -------------- If yes, date m
of last test
No

m

y

y

Don’t know
Declined
Not Asked

If yes, specify:

Self-reported Previous HIV Test Result

___________________________________









___________________________________
2. Have you had sex in the past 12 months (vaginal or anal):

5. In the past 12 months, have you
been diagnosed with any of the
following STDs (not HIV)?

a – Without using a condom?

 Yes  No

b – With person who is HIV positive?

 Yes  No

Chlamydia

 Yes  No

c – In exchange for drugs, money, or gifts?

 Yes  No

Gonorrhea

 Yes  No

d – While using alcohol?

 Yes  No

Syphilis

 Yes  No

e – While using drugs?

 Yes  No

Other

 Yes  No

HIV Test 1

HIV Test 2

Positive
Negative
Preliminary positive
Indeterminate
Don’t know
Declined
Not asked

For clients who tested HIV positive
Was client given a TB
test?

 Yes

 No

Was client referred to
HIV prevention
services?

 Yes

 No

Was client referred to
medical care?

 Yes

 No

If female, is client
pregnant?

 Yes

 No

 Yes

 No

Was client referred to
 Yes
Partner Counseling and
Referral Services
(PCRS)?

 No

Test ID number
Sample date

m

m

d

d

y

y

m

m

d

d

Test election:

 Tested anonymously
 Tested confidentially
 Declined testing

 Tested anonymously
 Tested confidentially
 Declined testing

Test technology:

 Conventional
 Rapid

 Conventional
 Rapid

Specimen type:













Test result:

 Positive/reactive
 Negative
 Indeterminate

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

Result provided?  Yes

 Invalid
 No result

 No

y

y

If yes:
Is client in prenatal
care?

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

 Positive/reactive
 Negative
 Indeterminate
 Yes

 Invalid
 No result

 No

Local Use Fields
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Date provided:
If results not
provided, why
not?

m

m

d

d

y

y

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

m

m

d

d

y

y

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

Public reporting burden of this collection information is about 3 minutes. An agency may not conduct or sponsor, and a person is not required to res pond to the collection unless it displaysa currently
valid OMB Control #. Send comments or suggestions to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Rd, NE, MS D-79, Atlanta, GA 30333; ATTN: PRA 0920-0696.

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