Interview Audit Form
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3Program Operating Procedures and Standards
Interview Audit Form
Worker Name_______________________ DIS/Worker # ____________ Reviewing Supervisor # __________
Date of Interview Audit_____________ Field OIX_____ Clinic OIX_____
Communication Acceptable Unacceptable
Areas observed
Acceptable
Unacceptable
1. Performs pre-interview analysis.
2. Establishes appropriate, professional rapport.
3. Pursues detailed description and locating information on all sex partners
and clusters. Effectively elicits social and sexual network information.
4. Uses open-ended questions effectively.
5. Provides factual disease and prevention messages to patient.
6. Interview progresses in format that follows DIS guidelines.
7. Communicates at a level and in a language in which the patient is open
and comfortable.
8. Emphasizes confidentiality in an appropriate manner.
9. Provides referrals (as needed) to the patient for partner self-referral.
Problem Solving
10. Addresses patient concerns in an appropriate manner.
11. Clearly and convincingly uses STD motivators to overcome obstacles.
Analytical Capabilities
12.Computes and uses interview periods before interview, but remains
open to additional information that may influence that.
13. Recognizes exposure gaps and uses them to challenge patient.
14. Recognizes and confronts discrepancies in patient responses.
Disease Intervention Behaviors
15. Asks purposeful questions using information obtained prior to and during
the interview.
16. Asks questions successfully leading to venues or locales for case-related
screening activities.
Risk Reduction
17. Accurately assesses patient risk factors. Discusses relevant risk-reduction
messages based on the risk-factor assessment.
Interview Follow-Through
18. Establishes specific contracts and timelines with clients regarding
their sexual partners and commitments made to the DIS.
19. Sets specific date and time for re-interview to occur within 7 days of the
original interview.
20. Provides appropriate referrals per needs identified though conversation
with patient.
Total # of acceptable/unacceptable outcomes
DIS Signature ____________________________________ Date _____________
Signature means only that DIS has reviewed comments. This signature does not constitute agreement with the
evaluation
Supervisor’s Signature____________________________________________________Date____________
Dec 2009
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