HIV test form - page 2

National HIV Prevention Program Monitoring and Evaluation (NHM&E)

Attachment 3 B HIV Test Form Page 2

Counseling, Testing and Referral for Community-Based Organizations

OMB: 0920-0696

Document [pdf]
Download: pdf | pdf
	


	



.$	/	"!
2

.,7
)3##"=*9/1>;?>?
@#	A

B%$$ %3	
	
	
5	$%"3"	$	&
<
1

'

'

+%
""$	"%
	##3&

<

+%
 &

0!

1

$	$	"	
$"$"	
5	$%"2+:.&

,%	$

<
1

'

5	$%".,&

'

<
1
+%%3	$
$#	&
+%
#		$	&
<
<
1
1
0!
0!
$"
$"
1	!"
1	!"

+%
 	$%"
%#		$	&
+%
""$	"%
<
#		$		##3&
1
<
1
0!

'	$()$"
'A

'

'E

'>

'E

'

'

'

'?

'

'?

'

'

'

()$"


?

E





A

'

'

'

1
.*$

3XEOLFUHSRUWLQJEXUGHQRIWKLVFROOHFWLRQRILQIRUPDWLRQLVHVWLPDWHGWRDYHUDJHPLQXWHVSHUUHVSRQVHLQFOXGLQJWKHWLPHIRUUHYLHZLQJLQVWUXFWLRQVVHDUFKLQJH[LVWLQJGDWDVRXUFHVJDWKHULQJDQGPDLQWDLQLQJWKHGDWD
QHHGHGDQGFRPSOHWLQJDQGUHYLHZLQJWKHFROOHFWLRQRILQIRUPDWLRQ $QDJHQF\PD\QRWFRQGXFWRUVSRQVRUDQGDSHUVRQLVQRWUHTXLUHGWRUHVSRQGWRDFROOHFWLRQRILQIRUPDWLRQXQOHVVLWGLVSOD\VDFXUUHQWO\YDOLG20%
&RQWURO1XPEHU 6HQGFRPPHQWVUHJDUGLQJWKLVEXUGHQHVWLPDWHRUDQ\RWKHUDVSHFWRIWKLVFROOHFWLRQRILQIRUPDWLRQLQFOXGLQJVXJJHVWLRQVIRUUHGXFLQJWKLVEXUGHQWR&'&$76'55HSRUWV&OHDUDQFH2IILFHU
&OLIWRQ5RDG1(06'$WODQWD*HRUJLD$77135$
C




File Typeapplication/pdf
File TitleHIV Test Form - Part 2
Subjectreferral, services
AuthorHHS CDC NCHHSTP DHAP PEB
File Modified2009-10-13
File Created2009-10-13

© 2024 OMB.report | Privacy Policy