Male Partner Eligibility Form

ZEN Colombia: Male Partner Eligibility

Name of Person Completing the Form: _______________________________________________

Today’s date: _____/______/________

DD MMM YYYY

Clinic Information

Clinic name: _________________________________________

City: □ Barranquilla □ Cali

Patient Information

Last name: _________________________________________

First name: _________________________________________

Eligibility Criteria

Did the pregnant partner agree that this man can be asked to be included in the study?	□ Yes □ No
Does this man live in the same household as the pregnant partner enrolled in ZEN? (ID #:_____________________)	□ Yes □ No
Is this man aged 18 years or older?	□ Yes □ No
Does this man speak Spanish?	□ Yes □ No

Exclusion Criteria

Is this man incarcerated?	□ Yes □ No
Is this man unable to physically or psychologically participate based on clinical judgement?	□ Yes □ No

Eligibility Determination

This man is eligible for the study. (All answers to eligibility criteria questions are Yes AND all answers to exclusion criteria are No.)

□ Yes □ No

Zika Information Sheet Distribution

Did you give the patient an information sheet on preventing Zika virus before he left?

□ Yes, he took it □ Offered, but he didn’t want/take it □ Not offered

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