Form Program Specific I Program Specific I Program Specific Indicators

OMB No. 0930-0xxx

Expiration Date: xx/xx/xx

Attachment 3

Co-location and Integration of HIV Prevention and Medical Care into Behavioral Health Programs

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 35 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.

MAI Program Measures:

1. Report at baseline only: HIV status, report rapid HIV test results

☐Positive/Reactive ☐Negative/Non-reactive

☐ Unknown

2. Report at baseline only: Has client been diagnosed HIV positive, prior to this assessment?

☐No, New Diagnosis ☐ Yes, Existing Diagnosis

☐ Unknown

3. Report at baseline only: If this is a new diagnosis, is patient classified as having a Stage 3 HIV infection (AIDS)?¹

☐ Yes ☐ No

☐Unknown

4. Report at baseline only: Has client received ART treatment for HIV, prior to this assessment?

☐ New to Treatment ☐ Currently in Treatment

☐ Returning to Treatment ☐ Unknown

5. Report at baseline only: What is the client’s CGI-Severity rating for behavioral health?

CGI-S Score__________________ DATE of Rating___________

5. Report at each reassessment: What is the client’s CGI-Improvement rating for his/her behavioral health?

Behavioral Health (CGI-I)_______________ DATE of Rating___________

5. Report at baseline and each reassessment: What is the client’s Karnofsky Performance Scale percentage for physical health?

Karnofsky Scale Percentage____________________ DATE of Rating___________

5. Report at first six-month reassessment only: Did the client attend a routine HIV medical care visit within 3 months of current HIV diagnosis?

☐ Yes ☐ No

☐ Unknown

5. 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) since Last Reassessment__________________________________________

☐ No

5. Report at baseline and all reassessments: Has the client been prescribed Antiretroviral Medication (ART), in past 6 months?

☐ Yes

☐ No ☐ Not Applicable

5. Report at baseline and all reassessments: Most recent Viral Load Count (copies/ml) ___________________ DATE of Test___________

5. Report at each reassessment: Date client left the program/ or last date client received medical services: _______________

1 http://www.who.int/hiv/pub/guidelines/HIVstaging150307.pdf