Attachment 8
OMB No. 0930-XXXX
Expiration Date:
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-XXXX. Public reporting burden for this collection of information is estimated to average 20 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. 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.
Report at baseline only: What is the client’s current HIV status?
☐Positive/Reactive ☐Negative/Non-reactive
☐ Unknown
Report at baseline only: Has the client been diagnosed HIV positive, prior to this assessment?
☐No, this was a new HIV diagnosis ☐ Yes, the client had been previously diagnosed as HIV positive prior to this assessment.
☐ Unknown
Report at baseline and all reassessments: Has the client been prescribed antiretroviral therapy (ART) in the past 6 months, including at this assessment?
☐ Yes
☐ No
☐ Unknown
Report at baseline only: Had the client been prescribed ART PRIOR to this assessment?
☐ Yes, and the client had a current prescription for ART at the time of this assessment.
☐ Yes, but the client DID NOT have a current prescription for ART at the time of this assessment.
☐ No, the client had not been prescribed ART therapy at any time in the past.
☐ Unknown
Report at first reassessment only: Did the client attend a routine HIV medical care visit within three months of HIV diagnosis?
☐ Yes ☐ No
☐ Unknown
Report at first reassessment only: Was the client classified as having a Stage 3 HIV infection (AIDS) within three months of HIV diagnosis?1
☐ Yes ☐ No
☐Unknown
Report at baseline and each reassessment: Did the client have at least one HIV medical care visit in the past 6 month period?
☐ Yes, List Dates of all HIV-Related Medical Visit(s) in the Last Six Months or Since Their Last Reassessment__________________________________________
☐ No
☐ Unknown
Report at baseline and all reassessments: Most recent Viral Load Count (copies/ml) ___________________ DATE of Test___________
☐ Unknown
1 http://www.who.int/hiv/pub/guidelines/HIVstaging150307.pdf
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Sarah Taylor |
| File Modified | 0000-00-00 |
| File Created | 2021-01-26 |