Att4.1 HBV- HEPTLC Data Collection Template

EVALUATIONWEB ® 2012 HepTLC Hepatitis B Test Template
General Instructions for completing the EvaluationWeb HepTLC Hepatitis B Test Template
This Hepatitis B testing data collection template is provided to assist CDC grantees who are collecting PPHF Viral
Hepatitis/Evaluation of Testing and Linkage to Care data. This template is not mandated for use in the field and
may be customized so that an agency may make changes to the template to best fit their needs. Agencies may add
additional local questions/variables to the template, but none of the CDC variables may be deleted or modified. The
template contains the CDC Assurance of Confidentiality statement at the bottom. This statement assures clients and
agency staff that data collected and recorded on the templates will be handled securely and confidentially. All
grantees are encouraged to utilize the CDC Assurance of Confidentiality statement on all client level data collection
templates used in Hepatitis B and C testing and linkage to care programs.

The template can only be accessed and downloaded from EvaluationWeb or by requesting a copy via CDC. The
manipulatable Publisher template will only be available by contacting your ICF Macro Data Manager. There are no
pre-printed barcodes on any template forms. You must adhere or write in the Form Identification sticker (barcode)
to each page to link the client’s information. This template is not intended for use as an Optical Character Recognition (OCR) document; it cannot be scanned.

This template is designed for ease of data collection and direct data entry into EvaluationWeb. The template follows the EvaluationWeb direct data entry screens beginning from top upper left column A to bottom left, then to upper right column B to bottom right.

A

B

There are two different response formats that you will use to record data: (1) text boxes and (2) check boxes. Text
boxes are used to record hand written information (codes and dates). Check boxes are used to select only one response unless otherwise indicated on the template.

Please refer to the Appendix A for all agency and site IDs and Appendix B for codes for country of origin. Please print
these documents for your reference.

To add new site locations contact the HELP DESK at Luther Consulting via email at [email protected] or by
telephone 1-866-517-6570 option #1.

For agencies directly entering data into EvaluationWeb it may not be necessary to complete the Agency Name.
Assurance of Confidentiality Statement:
The information in this report to the Centers for Disease Control and Prevention (CDC) is collected under the
authority of Sections 304 and 306 of the Public Health Service Act, 42 USC 242b and 242k. Your cooperation is necessary for evaluation of the interventions being done to understand and control Hepatitis. Information in CDC’s Hepatitis/Evaluation of Early Identification and Linkage to Care system that would
permit identification of any individual on whom a record is maintained, or any health care provider collecting HepTLC information, or any institution with which that health care provider is associated will be
protected under Section 308(d) of the Public Health Service Act. This protection for the HepTLC information includes a guarantee that the information will be held in confidence, will be used only for the purposes stated in the Assurance of Confidentially on file at CDC, and will not otherwise be disclosed or released without the consent of the individual, health care provider, or institution described herein in accordance with Section 308(d) of the Public Health Service Act (42 USC 242m(d)).
HepTLC: Hepatitis B

12/21/2012

Enter or adhere Form ID

EVALUATIONWEB ® 2012 HepTLC Hepatitis B Test Template

Site Information

Man who has had Anal Sex with a Man or Male
Transgender

See Appendix for a list of Agency and Site IDs
Agency Name

 Ever, yes

If yes, in the past 12 months?

Agency ID

 Ever, no

 Yes

Site ID

 Don’t Know

 No

 Declined to Answer

 Don’t Know

 Not Asked

 Declined to Answer

Client Demographics
Client ID

 Not Asked

Country of Origin
code (See Appendix)

Household Contact with a Person Known to be Infected
with HBV

Year of Birth (yyyy)
Gender (Select one)

 Male
 Female
 Transgender

 Declined to Answer
 Additional, specify:
___________________
Race (Select all that apply)

 American Indian/Alaskan
Native
 Asian
 Black/African American

 Native Hawaiian/Pacific
Islander
 White
 Don’t Know
 Declined to Answer
Ethnicity (Select one)

 Hispanic/Latino
 Not Hispanic/ Latino

 Don’t Know
 Declined to Answer

 Ever, yes

If yes, in the past 12 months?

 Ever, no

 Yes

 Don’t Know

 No

 Declined to Answer

 Don’t Know

 Not Asked

 Declined to Answer
 Not Asked

Sexual Partner of Person Infected with HBV
 Yes

 Don’t Know

 No

 Declined to Answer
 Not Asked

Multiple Sexual Partners

Health Insurance

More than one partner during a 6 month period

If yes, what type?

 Yes

(Select one)

 Yes

 Don’t Know

 No

 Declined to Answer

 Not Asked

 No

 Public

 Don’t Know

 Private

Self-reported Pregnancy Status

 Declined to Answer

 Other

Female or Transgender Only

 Don’t Know

 Yes

 Don’t Know

 Declined to Answer

 No

 Declined to Answer

 Not Asked

Risk Factors
HIV Positive Status

Injection Drug Use
 Ever, yes

If yes, in the past 12 months?

 Yes

If yes, source of HIV positive status?

 Ever, no

 Yes

 Don’t Know

 No

 No

 Self Reported

 Don’t Know

 Declined to Answer

 Don’t Know

 Don’t Know

 Not Asked

 Declined to Answer

 Declined to Answer

 Documented
Test

 Declined to Answer

 Not Asked

 Not Asked

HepTLC: Hepatitis B

12/21/2012

 Not Asked
2

Enter or adhere Form ID

EVALUATIONWEB ® 2012 HepTLC Hepatitis B Test Template
Client ID

Hepatitis B Test Results

Test Date

Hepatitis B Core Antibody (Anti-HBC)

Hepatitis B Surface Antigen (HBsAg)

__ __ /__ __ /__ __ __ __

__ __ / __ __ /__ __ __ __















Lab Type

Results

Were Test Results Provided?

Date Test Results
Provided
If Results NOT
Provided, Why?

Was Client Referred to Medical Care? (HBsAg Positives Only)














Public
Private
Unknown
Not Applicable
Positive
Negative
Indeterminate
Invalid
No Result
Not Applicable
Yes
No
Yes, Results from
Other Agency

Public
Private
Unknown
Not Applicable
Positive
Negative
Indeterminate
Invalid
No Result
Not Applicable
Yes
No

If yes, date:

__ __ /__ __ /__ __ __ __

__ __ /__ __ /__ __ __ __

 Refused Notification
 Could Not Locate
 Don’t Know
 Other, Specify:
___________________

 Refused Notification
 Could Not Locate
 Don’t Know
 Other, Specify:
___________________

How linked?

 Referred to Primary Care
Physician
 Referred to Specialist
 Other, Specify:
_________________________
 No

If no, why?

 Could Not Be Located
 Not Offered
 Don’t Know
 Other, Specify:
_________________________
 Don’t
Know
Documentation of 1st Medical Appointment
(HBsAg Positives Only)

 Yes

If yes, date:

 No

If no, why?

__ __ / __ __ /__ __ __ __
 Moved

 Declined to Answer

 Deceased

 No

 Not Asked

 Incarcerated
 Declined to be Linked
 Lost to Follow-up

 Hepatitis A

 Don’t Know

 Hepatitis B

 Declined to Answer

(Select one)

 Hep A and Hep B

 Not Asked

 Already in HBV Care
 Don’t Know
 Other, Specify:

Post Test Follow-up
Post Test Counseling (HBsAg Positives and High Risk Negatives Only)
 Yes
If yes, date:
__ __ / __ __ /__ __ __ __
Type
Check all that
apply

HepTLC: Hepatitis B

 Refused

 Yes

If yes, types of
Hepatitis
Vaccine

 Don’t Know

 Set Up Appointment with
Specialist
 Referred to Medical Facility

 Don’t Know

 No

__ __ / __ __ /__ __ __ __
 Set Up Appointment with
Primary Care Physician

 Yes, Results from
Other Agency

Hepatitis Vaccine
Ever had a
Hepatitis
Vaccine?

 Yes

If no, why?

 Alcohol
 Risk Reduction
 Medical Education

______________________
__
 In Progress
 Don’t Know
Reported to Surveillance
(HBsAg Positives Only)

 Declined
 Lost to Follow-up
 Not Offered
 Other, specify:
_________________________
12/21/2012

 Yes

If yes, date:

__ __ / __ __ /__ __ __ __

 No
 Don’t Know

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APPENDIX A

EVALUATIONWEB ® 2012 HepTLC Hepatitis B Test Template

Codes for Agency ID
1 African Services Committee
2 AIDS Resource Center of Wisconsin
3 Anthony Jordan Health Center
4 Asian Health Coalition
5 City and County of San Francisco
6 Damian Family Care Centers, Inc.
7 Denver Health and Hospital Authority
8 Downeast AIDs Network Inc.
9 Durham County
10 Emory University School of Medicine
11 Family and Medical Counseling Service, Inc.
12 Fund for Public Health in NY, Inc.
13 Fundacion Investigacion de Diego
14 Help PSI Services Corp.
15 Hope Health Inc.
16 Med Star Health Research Institute
17 Minnesota Department of Health
18 Multnomah County Health Department
19 National Nursing Centers Consortium

20 Ohio Asian American Health Coalition
21 Seattle-Kings County Health Department
22 Southern Arizona AIDS Foundation
23 St. Joseph’s Hospital & Medical Center (Center for Liver &
Hepatobiliary Disease) A Dignity Health Member
24 Tarzana Treatment Centers
25 HIV Education and Prevention Project of Alameda County
26 University of California at Davis
27 University of California, San Diego
28 University of Utah Health Care
29 University of Texas, Health Science Center
31 University of Florida
32 University of Illinois
33 Virginia Department of Health
34 Hawaii Department of Health
35 Johns Hopkins University
36 University of Alabama

Codes for Site ID

HepTLC: Hepatitis B

12/21/2012

4

APPENDIX B

EVALUATIONWEB ® 2012 HepTLC Hepatitis B Test Template

Codes for Country of Origin
US Codes
1 United States
2 American Samoa
3 Guam
4 Northern Mariana Islands
5 Pacific Trust Territories
6 Puerto Rico
7 Virgin Islands, U.S.
8 Wake Island
9 U.S. Misc Carribbean
10 U.S. Misc Pacific #1
Non-US Codes
11 Afghanistan
12 Albania
13 Algeria
14 Andorra
15 Angola
16 Anguilla [British overseas territory]
17 Antarctica
18 Antigua and Barbuda
19 Argentina
20 Armenia
21 Aruba
22 Australia
23 Austria
24 Azerbaijan
25 Bahamas
26 Bahrain
27 Bangladesh
28 Barbados
29 Belarus
30 Belgium
31 Belize
32 Benin
33 Bermuda [British Territory]
34 Bhutan
35 Bolivia
36 Bosnia and Herzegovina
37 Botswana
38 Brazil
39 Britain Indian Ocean Territory
[British Territory]
40 Brunei Darussalam
41 Bulgaria
42 Burkina Faso
43 Burundi
44 Cambodia
45 Cameroon
46 Canada
47 Cape Verde
48 Cayman Islands [British Territory]
49 Central African Republic
50 Chad
51 Chile
52 China
53 Colombia
54 Comoros
55 Congo
56 Congo, the Democratic Republic
of the [Zaire]
57 Cook Islands
58 Costa Rica
59 Cote d'Ivoire [Ivory Coast]
60 Croatia
61 Cuba
62 Cyprus
63 Czech Republic
64 Denmark
65 Djibouti
66 Dominica
HepTLC: Hepatitis B

67 Dominican Republic
68 East Timor [Timor –Leste]
69 Ecuador
70 Egypt
71 El Salvador
72 Equatorial Guinea
73 Eritrea
74 Estonia
75 Ethiopia
76 Falkland Islands [Malvinas] [British
Territory]
77 Faroe Islands [Danish Territory]
78 Fiji
79 Finland
80 France
81 French Guiana [French Territory]
82 French Polynesia
83 Gabon
84 Gambia
85 Georgia
86 Germany
87 Ghana
88 Gibraltar [British Territory]
89 Greece
90 Greenland
91 Grenada
92 Guatemala
93 Guinea
94 Guadeloupe [French Territory]
95 Guinea-Bissau
96 Guyana
97 Haiti
98 Holy See (Vatican City State)
99 Honduras
100 Hong Kong
101 Hungary
102 Iceland
103 India
104 Indonesia
105 Iran, Islamic Republic of
106 Iraq
107 Ireland
108 Israel
109 Italy
110 Jamaica
111 Japan
112 Jordan
113 Kazakhstan
114 Kenya
115 Kiribati
116 Korea, Democratic People's Republic
of (North)
117 Korea, Republic of (South)
118 Kuwait
119 Kyrgyzstan
120 Lao People's Democratic Republic
121 Latvia
122 Lebanon
123 Lesotho
124 Liberia
125 Libyan Arab Jamahiriya
126 Liechtenstein
127 Lithuania
128 Luxembourg
129 Macao
130 Macedonia, the Former Yugoslav
Republic of
131 Madagascar
132 Malawi
133 Malaysia
134 Maldives
135 Mali
136 Malta
12/21/2012

137 Marshall Islands
138 Martinique [French Territory]
139 Mauritania
140 Mauritius
141 Mayotte [French Territory]
142 Mexico
143 Micronesia, Federated States of
144 Moldova, Republic of
145 Monaco
146 Mongolia
147 Montenegro
148 Montserrat [British Territory]
149 Morocco
150 Mozambique
151 Myanmar [Burma]
152 Namibia
153 Nauru
154 Nepal
155 Netherlands
156 Netherlands Antilles
157 New Caledonia [French Territory]
158 New Zealand
159 Nicaragua
160 Niger
161 Nigeria
162 Niue
163 Norfolk Island [Australian Territory]
164 Norway
165 Oman
166 Pakistan
167 Palau
168 Palestinian Territories
169 Panama
170 Papua New Guinea
171 Paraguay
172 Peru
173 Philippines
174 Poland
175 Portugal
176 Qatar
177 Reunion [French Island]
178 Romania
179 Russia
180 Rwanda
181 Saint Christopher [Saint Kitts
and Nevis]
182 Saint Helena [British Territory]
183 Saint Lucia
184 Saint Pierre and Miquelon
[French Territory]
185 Saint Vincent and the Grenadines
186 Samoa
187 San Marino
188 Sao Tome and Principe
189 Saudi Arabia
190 Senegal
191 Serbia
192 Seychelles
193 Sierra Leone
194 Singapore
195 Slovakia
196 Slovenia
197 Solomon Islands
198 Somalia
199 South Africa
200 South Sudan
201 Spain
202 Spanish North Africa
203 Sri Lanka
204 Sudan
205 Suriname

206 Swaziland
207 Sweden
208 Switzerland
209 Syrian Arab Republic
210 Taiwan
211 Tajikistan
212 Tanzania, United Republic of
213 Thailand
214 Togo
215 Tokelau [New Zealand
Territory]
216 Tonga
217 Trinidad and Tobago
218 Tunisia
219 Turkey
220 Turkmenistan
221 Turks and Caicos Islands
[British Territory]
222 Tuvalu
223 Uganda
224 Ukraine
225 United Arab Emirates
226 United Kingdom
227 Uruguay
228 Uzbekistan
229 Vanuatu
230 Venezuela
231 Vietnam
232 Virgin Islands, British
[British Territory]
233 Wallis and Futuna
[French Territory]
234 Western Sahara
235 Yemen
236 Zambia
237 Zimbabwe
777 Declined to Answer
888 Other
999 Don't Know

5