Form HIV Testing Form HIV Testing Form HIV Testing Form

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MB No. 0930-03x Expiration Date: xx/xx/xx

OMB No. 0930-03x Experation Date: XX/XX/XX

Attachment 1

Public Burden Statement: 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 OMB control number for this project is 0930-0xxx.  Public reporting burden for this collection of information is estimated to average 8 minutes per respondent, per year, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to SAMHSA Reports Clearance Officer, 1 Choke Cherry Road, Room 2-1057, Rockville, Maryland, 20857.

SAMHSA MAI Rapid HIV/HEPATITIS Testing Clinical Information Form

SECTION A: SITE CHARACTERISTICS 1. Date of visit (mm/dd/yyyy): 2. Grantee #: 3. Partner ID (if applicable): 4. CLIENT ID: 5. Site type code # (see site code on back page)

SECTION B: DEMOGRAPHICS

1. Gender

3. Race

4. Age

5. Previous HIV Test

6. Previous Viral Hepatitis Test

(check one)

(check all that apply)

(check one)

Male

Alaska Native/ American Indian

<18 years

Yes No

Yes No

Female

18-24 yrs

If Yes: (check one)

If Yes: (check one)

Transgender

Asian

25-34 yrs

Result was negative

Result was negative

Black/African American

35-44 yrs

Result was positive

Result was positive

2. Ethnicity

Native Hawaiian/ Other Pacific Islander

45-54 yrs

Result was inconclusive

Result was inconclusive

(check one)

55-64 yrs

Result was unknown

Result was unknown

Hispanic

White

65+ yrs

Non-Hispanic

SECTION C: 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 female had unprotected sex with a transgender individual had unprotected sex with significant other in a monogamous relationship had unprotected sex with multiple partners had unprotected sex with an HIV positive person had unprotected sex with an Hepatitis positive person had unprotected sex while high on drugs/alcohol

had unprotected sex with a person who injects drugs had unprotected sex with a man who has sex with men exchanged sex for drugs/money/shelter been diagnosed with sexually transmitted disease (syphilis, chlamydia, gonorrhea, herpes) refusal the client reports no known sexual risk factors

2. During the past 30 days have you used: from the date of this form (check all that apply)

4 or more alcoholic drinks in 1 sitting (for men) 3 or more alcoholic drinks in 1 sitting (for women) cocaine (crack)

marijuana ecstasy heroin methamphetamine

non-medical use of prescription drugs shared injection equipment (i.e. needle and drug paraphernalia) refusal the client reports no known substance use risk factors other (specify)

3. Have you (check all that apply)

been diagnosed with alcohol or drug dependence, in the past 12 months been in alcohol or drug treatment in the past 12 months ever been in alcohol or drug treatment

been diagnosed with psychological distress, in the past 12 months (e.g., major depression, anxiety disorder) ever received treatment for psychological distress during the past 12 months? (e.g., major depression, anxiety disorder) none of the above

SECTION D: Rapid HIV TESTING RESULTS

SECTION E: Rapid HEPATITIS B & C TESTING RESULTS

1. Rapid HIV test result (check one)

1. Rapid Hepatitis test results (check all)

Negative/Non-reactive

Positive/Reactive

 Hepatitis B

Hepatitis C

Invalid (Repeat test) Refusal

Positive/Reactive

Positive/Reactive

Negative/Non-reactive

Negative/Non-reactive

Invalid (Repeat test) Refusal 

Invalid (Repeat test) Refusal

2. Did client receive result of rapid HIV test? (check one)

2. Did client receive results of rapid HEP test? (check one)

Yes

No

Yes

No

3. Retest HIV Result: (check one)

3. Retest HEP Result: (check one)

Negative/Non-reactive

Positive/Reactive

Negative/Non-reactive

Positive/Reactive

Invalid/indeterminate

N/A

Invalid/indeterminate

N/A

4. Did client receive retest result of test? (check one) Yes No

4. Did client receive retest results of test? (check one) Yes No

SECTION F: CONFIRMATORY TESTING of HIV

SECTION G: CONFIRMATORY TESTING of HEP B & C Test

(if rapid HIV test result is positive/reactive)

(if rapid Hepatitis test result is positive/reactive)

1. Confirmatory HIV test result (check one)

1. Confirmatory HEP test result (check one)

 Negative/Non-reactive

 Positive/Reactive

 Negative/Non-reactive

 Positive/Reactive

 Invalid/indeterminate

Results pending

 Invalid/indeterminate

Results pending

2. Type of confirmatory test (check one)

2. Type of confirmatory test (check one)

Blood (plasma, serum, or blood spot)

Blood (plasma, serum, or blood spot)

Oral

Urine

SECTION H: TYPE OF HIV SERVICES PROVIDED	SECTION I: TYPE OF Hepatitis SERVICES PROVIDED
(Check all that apply)	(Check all that apply)
HIV Pre/Post- Prevention Counseling	Hepatitis Pre/Post- Prevention Counseling
HIV Pre/Post-Test Counseling	 Hepatitis Pre/Post-Test Counseling
HIV Testing	Viral Hepatitis Testing
Referred to HIV Care and Treatment Services	 Hepatitis Vaccination
		Yes	A	Date 1:_________________
Linked to HIV care treatment after positive confirmation (Client attended a routine HIV medical care visit in last 3 months)			B	Date 2: _________________
			 Twinrix	Date 3: _________________
Linked to HIV prevention/ancillary services if negative		No__________________________________
test result	Referred to Hepatitis Care after positive confirmation
	Linked to Hepatitis care treatment after positive confirmation
	(Client attended a routine Hepatitis medical care visit in last 3 months)
	Linked to Hepatitis prevention/ancillary services if negative
	test result

SAMHSA MAI Rapid HIV Testing Clinical Information Form

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Codes for Site Types

S01 S02 S03	Inpatient Facility Inpatient Hospital Inpatient-Drug/Alcohol Treatment	S16 S17 S18	Community Setting-AIDS Service Organization-non-clinical Community Setting-Community Center Community Setting-Shelter/Transitional housing
S04 S05 S06	Inpatient Facility-Other Outpatient-Drug/Alcohol Treatment Clinic Outpatient-HIV Specialty Clinic	S19 S20 S21	Community Setting-School/Education Facility Community Setting-Residential Community Setting-Public Area
S07 S08 S09	Outpatient-Community Mental Health Outpatient-Community Health Clinic Outpatient-TB Clinic	S22 S23 S24	Community Setting-Workplace Community Setting-Commercial Community Setting-Other
S10 S11 S12	Outpatient-School/University Clinic Outpatient-Prenatal/OBGYN Clinic Outpatient-Family Planning	S25 S26 S27	Community Setting-Bar/Club/Adult Entertainment Community Setting-Church/Mosque/Synagogue/Temple Correctional Facility
S13 S14 S15	Outpatient-Private Medical Practice Outpatient-Health Department/Public Health Clinic Outpatient-Health Department/Public Health Clinic-HIV	S28	Blood Bank, Plasma Center