Form Attachment A - HIV Attachment A - HIV Attachment A - HIV Form

Form Approved
OMB No. 0930-0295
Expiration Date: 09/30/2012

SAMHSA/CSAT MAI Rapid HIV Testing Clinical Information Form
SECTION A: SITE CHARACTERISTICS
2. Grantee #: ________________________________
4. CLIENT ID: _________________ (GPRA ID #)

1. Date of visit: ________________________________________
3. Partner ID (if applicable): ____________________
5. Site type code # (see site code on back page)______________

RAPID HIV TEST KIT LOT NUMBER:_________________________________________________________________________________

SECTION B: DEMOGRAPHICS
1. Gender
3. Race (check all that apply)
4. Age
5. Previous HIV Test
 Male
 Alaskan Native/American Indian
 <18 years
 No
 Female
 Asian
 18-24 yrs
 Yes
 Transgender
 Black/African American
 25-34 yrs
 Result was negative
 Native Hawaiian/Other Pacific Islander
 35-44 yrs
 Result was positive
2. Ethnicity
 White
 45-54 yrs
 Result was inconclusive
 Hispanic
 55-64 yrs
 Result was unknown
 Non-Hispanic
 65+ yrs
SECTION C: REASON FOR TEST OR REASON FOR REFUSAL TO TAKE TEST TODAY:
 Client took test. Reason for taking it: _____________________________
 Client refused test. Reason for refusal: ___________________________
SECTION D: RISK BEHAVIORS
1. During the past 30 days have you - from the date of this form (check all that apply)
 had unprotected sex with a male
 had unprotected sex with a person who injects drugs
 had unprotected sex with a female
 had unprotected sex with a man who has sex with men
 had unprotected sex with a transgender individual
 exchanged sex for drugs/money/shelter
 had unprotected sex with significant other in a monogamous relationship
 been diagnosed with sexually transmitted disease
 had unprotected sex with multiple partners
(syphilis, chlamydia, gonorrhea, herpes)
 had unprotected sex with an HIV positive person
 refusal
 had unprotected sex while high on drugs/alcohol
 the client reports no known sexual risk factors
2. During the past 30 days have you used: (check all that apply)
 4 or more alcoholic drinks in 1 sitting (for women)
 cocaine (crack)
 non-medical use of
 marijuana
prescription drugs
 shared injection equipment (i.e. needle and drug paraphernalia)
 methamphetamine
 5 or more alcoholic drinks in  refusal
1 sitting (for men)
 heroin
 the client reports no known substance use risk factors
 ecstasy
 other (specify) _______________
3. Have you (check all that apply)
 ever been in alcohol or drug treatment before today
 ever experienced serious psychological distress
 been in alcohol or drug treatment during the past 12 months
(e.g., major depression, anxiety disorder)
 none of the above
SECTION E: Rapid HIV TESTING RESULTS AND RETESTING RESULTS
1. Rapid HIV test results
2. Did client receive results of rapid HIV test?
 Negative/Non-reactive
 Positive/Reactive
 Yes
 Invalid (Repeat test using a new test kit.)
 No, reason ________________________
3. Retest Results:
4. Did client receive retest results of test?
 Negative/Non-reactive  Positive/Reactive  Invalid/indeterminate
 Yes
Rapid HIV test kit lot number (client retested):______________________  No, reason __________________________________
SECTION F: TYPE OF SERVICES PROVIDED (Check all that apply)
1. HIV Pre-Test/Prevention Counseling
3.  Linked to care treatment after positive confirmation
2. HIV Post-Test Counseling
4.  Linked to prevention/ancillary services if negative test result
This section applies to all services (e.g., linked to medical care) the client has been provided either by the Grantee or another agency,
up to and including the point at which the RHT Form is being completed.
SECTION G: CONFIRMATORY TESTING (if rapid HIV test result is positive/reactive)
1. Confirmatory test conducted
3. Confirmatory test results
 Yes
 Negative
 Indeterminate
 Yes: Client now wants a confirmatory test after initial refusal.
 Positive
 Results pending
 No, reason______________________________________
2. Type of confirmatory test
4. Did client receive results of confirmatory test?
 Blood (plasma, serum, or blood spot)
 Yes
 Oral  Urine
 No, reason ______________________________

Public reporting burden for 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, if all items are asked of a client/participant; to the
extent that providers already obtain much of this information as part of their ongoing client/participant intake or follow-up, less time will be required. Send comments
regarding this burden estimate or any other aspect of this collection of information to SAMHSA Reports Clearance Officer, Room 7-1044, 1 Choke Cherry Road,
Rockville, MD 20857. 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. The control number for this project is 0930-0295.

Form Approved
OMB No. 0930-0295
Expiration Date: 09/30/2012

SAMHSA MAI Rapid HIV Testing Clinical Information Form
Codes for Site Types
S01
S02
S03
S04
S05
S06
S07
S08
S09
S10
S11
S12
S13
S14
S15

Inpatient Facility
Inpatient Hospital
Inpatient-Drug/Alcohol Treatment
Inpatient Facility-Other
Outpatient-Drug/Alcohol Treatment Clinic
Outpatient-HIV Specialty Clinic
Outpatient-Community Mental Health
Outpatient-Community Health Clinic
Outpatient-TB Clinic
Outpatient-School/University Clinic
Outpatient-Prenatal/OBGYN Clinic
Outpatient-Family Planning
Outpatient-Private Medical Practice
Outpatient-Health Department/Public Health Clinic
Outpatient-Health Department/Public Health
Clinic-HIV

S16
S17
S18
S19
S20
S21
S22
S23
S24
S25
S26
S27
S28

Community Setting-AIDS Service Organization-non-clinical
Community Setting-Community Center
Community Setting-Shelter/Transitional housing
Community Setting-School/Education Facility
Community Setting-Residential
Community Setting-Public Area
Community Setting-Workplace
Community Setting-Commercial
Community Setting-Other
Community Setting-Bar/Club/Adult Entertainment
Community Setting-Church/Mosque/Synagogue/Temple
Correctional Facility
Blood Bank, Plasma Center