Hiv Counseling Information Form
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3State of California—Health and Human Services Agency
California Department of Public Health
HIV COUNSELING INFORMATION FORM
Session
date:
Unique ID:
Provider ID:
(mm/dd/yyyy)
Mark if CAQ was used
Agency ID:
Intervention ID:
Location ID:
(1)
HIV risk assessment: (
optional)
HIV test conducted?
Yes, test conducted
No, test not offered
No, client declined testing
(1)
(2)
(3)
Low
High
(1)
(2)
CLIENT INFORMATION
(mark one )
Date of birth:
Current gender identity:
(mm/dd/yyyy)
Health insurance coverage:
(mark all that apply )
Male
No coverage
Private
Medi-Cal (Medicaid)
(1)
(1)
(1)
(1)
Female
(2)
(1)
Family PACT
(1)
Low Income Health Program (LIHP)
(3)
Transgender: male to female
Medicare
Military
Indian Health Service
(1)
(1)
(1)
First letter of last name:
Declined
(9)
(4)
Transgender: female to male
Other public, specify:________________________
(1)
Other identity, specify: _____________
(5)
Residence county: ________________________
(mark one )
Declined to answer
HIV test before today?
(6)
Yes
Res.
Residence
(1)
(indicate recent HIV result & date)
:
Biological sex at birth
(mark one )
state:
zip code:
No
(0)
Male
(1)
Housing status:
Female
(8)
Client does not know
(2)
(currently)
(most severe in past 12 months)
Intersex
(3)
Declined to answer
(9)
Homeless
Homeless
(1)
(1)
(4)
Declined to answer
(2)
Unstably housed
(2)
Unstably housed
Most recent HIV result received:
(mark all that apply )
Race/ethnicity:
(mark one if tested before today)
Stably housed
Stably housed
(3)
(3)
Black/African American
(1)
Negative
Declined to answer
Declined to answer
(1)
(9)
(9)
American Indian/Alaska Native
(1)
Positive
Incarcerated for more than 24 hour period?
(2)
Asian, specify: ___________________
(1)
Yes
No
(past 12 months)
(1)
(0)
Preliminary positive
(3)
(no confirmatory result received)
Native Hawaiian/Pacific Islander, specify:
(1)
Migrant?
Yes
No
(currently)
(1)
(0)
Inconclusive, discordant, invalid
(4)
_______________________________
Client does not know
(mark one )
(5)
Sexual orientation:
Hispanic/Latino(a), specify:
(1)
Heterosexual or straight
(1)
Declined to answer
(9)
_______________________________
Bisexual
(2)
White
Date of last HIV test result:
(1)
(mm/yyyy)
(3)
Gay, lesbian, queer, or same gender loving
Client does not know
(1)
(4)
Other orientation, specify: ________________
(1)
Declined to answer
Client does not know
(5)
HIV TEST INFORMATION
Test sequence:
HIV TEST #1
HIV TEST #2
HIV TEST #3
Test ID:
Sample date:
(mm/dd/yyyy)
HIV test election:
Anonymous
Confidential
Anonymous
Confidential
Anonymous
Confidential
(1)
(2)
(1)
(2)
(1)
(2)
Test technology:
Rapid
Rapid
Rapid
(1)
(1)
(1)
(mark one )
(2)
Conventional
(2)
Conventional
(2)
Conventional
NAAT/RNA
NAAT/RNA
NAAT/RNA
(3)
(3)
(3)
Other test, specify: _______________
Other test, specify: _______________
Other test, specify: _______________
(4)
(4)
(4)
Test result:
Positive
Positive
Positive
(1)
(1)
(1)
(mark one )
Preliminary positive*
Preliminary positive*
Preliminary positive*
(2)
(2)
(2)
Negative
Negative
Negative
(3)
(3)
(3)
(4)
Indeterminate /Inconclusive
(4)
Indeterminate /Inconclusive
(4)
Indeterminate /Inconclusive
Invalid
Invalid
Invalid
(5)
(5)
(5)
*
*
*
Record confirmatory test result for preliminary
Record confirmatory test result for preliminary
Record confirmatory test result for preliminary
positive rapid tests (HIV TEST #2).
positive rapid tests (HIV TEST #3).
positive rapid tests (test #4).
Results provided?
Yes
Yes
Yes
(1)
(record date provided)
(1)
(record date provided)
(1)
(record date provided)
Date result provided:
Date result provided:
Date result provided:
(mm/dd/yyyy)
(mm/dd/yyyy)
(mm/dd/yyyy)
Provider ID:
Provider ID:
Provider ID:
(1)
Mark if client obtained result from
Mark if client obtained result from
(1)
Mark if client obtained result from
(1)
another agency
another agency
another agency
No
(0)
(indicate why)
(0)
No
No
(indicate why)
(0)
(indicate why)
If results not provided, why?
If results not provided, why?
If results not provided, why?
(1)
Client declined notification
Client declined notification
(1)
Client declined notification
(1)
Did not return / Could not locate
(2)
Did not return / Could not locate
(2)
Did not return / Could not locate
(2)
Other
(3)
Other
(3)
(3)
Other
HEPATITIS C (HCV) TEST INFORMATION
HCV test conducted?
HCV test type:
HCV test result:
HCV result
Referred to HCV
Date result provided:
Provider ID:
(mm/dd/yyyy)
(1)
Yes, test conducted
(1)
Rapid
(1)
Non-reactive
provided?
RNA testing?
(2)
No, test not offered
(2)
Conventional
(2)
Reactive
Yes
Yes
(1)
(1)
(3)
No, client declined
(3)
Home Access
(3)
Inconclusive
No
No
(0)
(0)
CDPH 8458 (07/14)
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