Att4.2 HCV- HEPTLC Data Collection Template

EVALUATIONWEB ® 2012 HepTLC HepaƟƟs C Test Template
General Instructions for completing the EvaluationWeb HepTLC Hepatitis C Test Template
This Hepatitis C 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 document 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 testing 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: Hepa

s C 

12/17/2012 

Enter or adhere

Form ID

EVALUATIONWEB ® 2012 HepTLC HepaƟƟs C Test Template

Site InformaƟon

Risk Factors

See Appendix for a list of Agency and Site IDs 

InjecƟon Drug Use (Op onal if tes ng as part of birth cohort recommenda ons)

Agency Name 

Agency ID 

Site ID 

Ever, yes   

Client Demographics

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 

Client ID 

Country of Origin  
Code (Op onal—See 
Appendix  for codes) 

Yes   

Year of Birth (yyyy) 

No 
Don’t Know 
Declined to Answer 
Not Asked 

HIV PosiƟve Status

Gender (Select one)
Male 
Female 
Transgender 

Declined to Answer 
Other, specify: 
___________________ 

Race (Select all that apply) 
American Indian/
Alaskan Na ve 
Asian 
Black/African Ameri‐
can 
Na ve Hawaiian/
Pacific Islander 

White 
Don’t Know 
Declined to Answer 

HepaƟƟs C Test Results

Test Date 
Lab Type 

Ethnicity (Select one) 
Hispanic/La no 
Not Hispanic/ La no 

Don’t Know 
Declined to Answer 

Test      
Technology 
Results 

Health Insurance
Yes   

If yes, what type? 
(Select one) 

No 

Public 

Don’t Know 

Private 

Declined to Answer 

Other 
Don’t Know 

Declined to Answer 
Notes:

HepTLC: Hepa

s C 

If yes, source of HIV posi ve status? (Select 
one) 
Self Reported 
Don’t Know 
Documented Test 
Declined to Answer 
Not Asked 

Were Test 
Results 
Provided? 

Date Test 
Results 
Provided 
If Results 
NOT     
Provided, 
Why? 

HepaƟƟs C
AnƟbody

AddiƟonal HCV AnƟbody (if applicable)

QualitaƟve HCV
RNA

__  __ / __  __ /__ __ __ __  

__  __ / __  __ /__ __ __ __  

__  __ / __  __ /__ __ __ 
__  

Public 
Private 
Unknown 
Not Applicable 
Rapid 
EIA 

Public 
Private 
Unknown 
Not Applicable 
Rapid 
EIA 
RIBA 

Posi ve 
Nega ve 
Indeterminate 
Invalid 
No Result 
Not Applicable 
Yes 
No 
Yes, Results from    
Other Agency  

Posi ve 
Nega ve 
Indeterminate 
Invalid 
No Result 
Not Applicable 
Yes 
No 
Yes, Results from 
Other Agency  

__ __ / __  __ /__ __ __ __  

__ __ / __  __ /__ __ __ __  

Public 
Private 
Unknown 
Not Applicable 

Posi ve 
Nega ve 
Indeterminate 
Invalid 
No Result 
Not Applicable 
Yes 
No 
Yes, Results 
from Other 
Agency 
__  __ / __  __ /__ __ __ 
__  

Refused          
Refused          No‐
No fica on 
fica on 
Could Not Locate  Could Not Locate 
Don’t Know 
Don’t Know 
Other, Specify:  
Other, specify:  
_______________  _______________ 

Refused          
No fica on 
Could Not Lo‐
cate 
Don’t Know 
Other, Specify:  
_______________ 
Addi onal tes ng variables con nue on page 3. 

12/17/2012 

2 

Enter or adhere Form ID

Client ID

EVALUATIONWEB ® 2012 HepTLC HepaƟƟs C Test Template

Post Test Follow-up
Post Test Counseling (HCV Ab Posi

HepaƟƟs C Test Results ConƟnued 

QuanƟtaƟve HCV RNA

HCV Genotype

(Required for ECHO Agencies; 
Op onal for Non‐ECHO Agen‐
cies) 

Test Date 

__  __ / __  __ /__ __ __ __  

Lab Type 

Results 

Yes 

Public 

Public 

Private 

Private 

Unknown 

Unknown 

Not Applicable 

Not Applicable 

Insert viral load below 

Genotype 1 

Genotype 2 

No 

Type 

Alcohol 
Risk Reduc on 
Medical Educa on 

If no, why? 

Declined 

(Select one) 

Lost to Follow‐up 
Other, Specify:  
_________________________ 

Don’t Know 

Post Test Counseling (HCV RNA Posi

Genotype 3 

Yes 

Genotype 5 

Genotype 6 
Not Applicable 

No 

__  __ / __  __ /__ __ __ __  

Type 

Alcohol 
Risk Reduc on 
Medical Educa on 

If no, why? 

Declined 

(Select one) 

Lost to Follow‐up 

Yes 

Yes 

No 

No 

Not Offered 

Yes, Results From   
Other Agency  

Yes, Results From   
Other Agency  

Other, Specify: 

Date Test Re‐
sults Provided 

__  __ / __  __ /__ __ __ __  

Refused No fica on 
Could Not Locate 
Don’t Know 
Other, Specify:  
_______________ 

________________________ 
Don’t Know 

__  __ / __  __ /__ __ __ __  

Refused No fica on 
Could Not Locate 
Don’t Know 
Other, Specify:  
_______________ 

Was Client Referred to Medical Care? (HCV RNA Posi
Yes 

Ever Had a        
Hepa s Vaccine? 

__   __ / __  __ /__ __ __ __  

How 
linked? 

Set Up Appointment With 
Primary Care Physician 

(Select one) 

Set Up Appointment With 
Specialist 
Referred to Medical Facility 

Yes 

Declined to Answer 

No 

Not Asked 

Referred to Primary Care 
Physician 
Other, Specify:  

Referred to Specialist 

Don’t Know 
If yes, type of Hep‐
a s Vaccine 
(Select one) 

Hepa

s A 

Don’t Know 

Hepa

s B 

Declined to Answer 

Hep A and Hep B 

ves Only) 

If yes, date: 

HepaƟƟs Vaccine 

ves Only) 

If yes, date: 

(Check all that 
apply) 

Genotype 7 

If Results NOT 
Provided, 
Why? 

__  __ / __  __ /__ __ __ __  

Not Offered 

Genotype 4 

Were Test 
Results        
Provided? 

If yes, date: 

(Check all that 
apply) 

__   __ / __  __ /__ __ __ __  

ves and High Risk Ab Nega ves) 

Not Asked 

_________________________ 
No 

If no, why? 

Refused 

(Select one) 

Could Not Be Located 
Not Offered 
Don’t Know 
Other, Specify:  
_________________________ 

Don’t Know 

Addi onal post test follow‐up variables con nue on page 4. 
HepTLC: Hepa

s C 

12/17/2012 

3 

Enter or adhere Form ID  

Client ID

EVALUATIONWEB ® 2012 HepTLC HepaƟƟs C Test Template

Notes:

Post Test Follow-up ConƟnued
DocumentaƟon of 1st Medical Appointment (HCV RNA Posi
Only)  
Yes  

ves 

If yes, date: 
__   __ / __  __ /__ __ __ __  

No  

If no, why? 

Moved 

(Select one) 

Deceased 
Incarcerated 
Declined to be linked 
Lost to follow‐up 
Already in HCV Care 
Don’t Know 
Other, specify:  
_______________________ 

In Progress   

Don’t Know   

AnƟviral Therapy (AVT)
(HCV RNA Posi ves Only)  

Required for ECHO Agencies; Op onal for Non‐ECHO Agencies 

Yes  

If yes, date: 

No 

__  __ / __  __ /__ __ __ __  
Pegylated interferon and 
Ribavirin 

AVT name:  

Pegylated interferon,      
Ribavirin and Telaprevir 
(Incivek) 

(Select one) 

Pegylated interferon,      
Ribavirin and Boceprevir 
(Victrelis) 
Don’t Know   

Reported to Surveillance

Yes  

If yes, date: 

No 

Don’t Know   

HepTLC: Hepa

s C 

__  __ / __  __ /__ __ __ __  

12/17/2012 

4 

APPENDIX A

EVALUATIONWEB ® 2012 HepTLC HepaƟƟs C 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: Hepa

s C 

12/17/2012 

5 

APPENDIX B
Codes for Country of Origin

EVALUATIONWEB ® 2012 HepTLC HepaƟƟs C Test Template

67 Dominican Republic
68 East Timor [Timor–Leste]
1 United States
69 Ecuador
2 American Samoa
70 Egypt
3 Guam
71 El Salvador
4 Northern Mariana Islands
72 Equatorial Guinea
5 Pacific Trust Territories
73 Eritrea
6 Puerto Rico
74 Estonia
7 Virgin Islands, U.S.
75 Ethiopia
8 Wake Island
76 Falkland Islands [Malvinas] [British
9 U.S. Misc Carribbean
Territory]
10 U.S. Misc Pacific #1
77 Faroe Islands [Danish Territory]
78 Fiji
Non-US Codes
79 Finland
80 France
11 Afghanistan
81 French Guiana [French Territory]
12 Albania
82 French Polynesia
13 Algeria
83 Gabon
14 Andorra
84 Gambia
15 Angola
16 Anguilla [British overseas territory] 85 Georgia
86 Germany
17 Antarctica
87 Ghana
18 Antigua and Barbuda
88 Gibraltar [British Territory]
19 Argentina
89 Greece
20 Armenia
90 Greenland
21 Aruba
91 Grenada
22 Australia
92 Guatemala
23 Austria
93 Guinea
24 Azerbaijan
94 Guadeloupe [French Territory]
25 Bahamas
95 Guinea-Bissau
26 Bahrain
96 Guyana
27 Bangladesh
97 Haiti
28 Barbados
98 Holy See (Vatican City State)
29 Belarus
99 Honduras
30 Belgium
100 Hong Kong
31 Belize
101 Hungary
32 Benin
102 Iceland
33 Bermuda [British Territory]
103 India
34 Bhutan
104 Indonesia
35 Bolivia
105 Iran, Islamic Republic of
36 Bosnia and Herzegovina
106 Iraq
37 Botswana
107 Ireland
38 Brazil
108 Israel
39 Britain Indian Ocean Territory
[British Territory]
109 Italy
40 Brunei Darussalam
110 Jamaica
41 Bulgaria
111 Japan
42 Burkina Faso
112 Jordan
43 Burundi
113 Kazakhstan
44 Cambodia
114 Kenya
45 Cameroon
115 Kiribati
46 Canada
116 Korea, Democratic People's Republic
of (North)
47 Cape Verde
117 Korea, Republic of (South)
48 Cayman Islands [British Territory]
118 Kuwait
49 Central African Republic
119 Kyrgyzstan
50 Chad
120 Lao People's Democratic Republic
51 Chile
121 Latvia
52 China
122 Lebanon
53 Colombia
123 Lesotho
54 Comoros
124 Liberia
55 Congo
56 Congo, the Democratic Republic of 125 Libyan Arab Jamahiriya
the [Zaire]
126 Liechtenstein
57 Cook Islands
127 Lithuania
58 Costa Rica
128 Luxembourg
59 Cote d'Ivoire [Ivory Coast]
129 Macao
60 Croatia
130 Macedonia, the Former Yugoslav
Republic of
61 Cuba
131 Madagascar
62 Cyprus
132 Malawi
63 Czech Republic
133 Malaysia
64 Denmark
134 Maldives
65 Djibouti
135 Mali
66 Dominica
136 Malta
US Codes

HepTLC: Hepa

s C 

12/17/2012 

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

6