Form Group Dosage Form Group Dosage Form Group Dosage Form

National Minority SA/HIV Prevention Initiative

GROUP DOSAGE FORM

Instructions: For each group program session, enter the Encounter Date and the Grant ID. For each service type received during the group session being recorded, circle the appropriate Group Service Code (see last page for service codes). Record the amount of time (in minutes) the service type lasted (rounded up to the next 5-minute interval) in the corresponding Duration Code space.

Enter the 5-digit Participant ID Number for each of the program participants attending the session. On this form, up to three services can be coded for each group session and up to 80 participants can be given a group service.

The Study Design Group Type (1=intervention group [pre-filled]), and the Administration Format (2=Group Format, [pre-filled]) boxes are only used in CSAP’s record keeping procedures.

Encounter Date Group Service Code Duration Code

Month		Day		Year			#1	11	11a	12	13			16	17	18
								19	20	21	21a	22	23	24	25			(Round up to next 5- minute interval)

Grant ID

S	P							#2	11	11a	12	13			16	17	18
									19	20	21	21a	22	23	24	25			(Round up to next 5- minute interval)

Grp. Type Adm. Frmt.

1		2		#3	11	11a	12	13			16	17	18
					19	20	21	21a	22	23	24	25			(Round up to next 5- minute interval)

Participant ID Numbers:

Participant ID Numbers:

Participant ID Numbers:

Participant ID Numbers:

GROUP SERVICE TYPES AND CODES

GROUP HEALTH CARE SERVICES
Code	Service
11	HIV Testing
11a	HCV Testing
12	Primary Health Care Services
13	Other Health Care Services
GROUP SERVICES
Code	Service	Code	Service
16	Support Group	21 21a	HIV Education STD Education
17	Group Counseling/Therapy	22	Substance Abuse Education
18	Skills Building Training/Education	23	Cultural Enhancement Activities
19	Health Education Classes/Sessions	24	Alternative Activities
20	Hepatitis Education	25	All Other Group Services

CSAP HIV Group Dosage Form – Last Updated 5/2015 Page 4