Specimens Collected During The Physical Exam (Hiv)
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1
2WOMEN'S INTERAGENCY HIV STUDY
SPECIMENS COLLECTED DURING THE PHYSICAL EXAM
FORM 31
ID LABEL
VISIT #:
FORM COMPLETED BY:
|__| - |__|__| - |__|__|__|__| - |__|
HERE --->
___ ___
___ ___ ___
VERSION DATE 10/01/10
ANY MISSING OR INCOMPLETE TEST RESULTS MUST BE EXPLAINED ON THIS FORM.
SECTION A. URINE TESTS
TEST TYPE
LOCATION
YES
NO
IF NO, SPECIFY REASON
N/A
A1. Pregnancy Test
Exam Site
1* (a)
2
______________________(A2)
3* (A2)
a.
DATE OF COLLECTION
/
/
M
D
Y
A2. Urine for repository
Freeze locally
1§ (a)
2
______________________(B1)
3§ (B1)
a.
DATE OF COLLECTION
/
/
M
D
Y
b. Time of collection:
|__|__| : |__|__|
AM……..1
PM……..2
* REQUIRED FOR EVERY WOMAN UNLESS SHE IS : S/P HYSTERECTOMY OR > 50 YEARS OF AGE.
§ COLLECT URINE FOR REPOSITORY ANNUALLY AT ODD VISITS ONLY (VISIT 31, VISIT 33, ETC.).
SECTION B. HAIR SPECIMEN
SPECIMEN TYPE
LAB
YES
NO
IF NO, SPECIFY REASON
N/A
B1. Hair
Central
1 (a)
2
(C1) 3 † (C1)
† Circle “N/A” only if participant is HIV-negative, or is HIV-positive and has not taken any antiretroviral
medications in the past four weeks.
a.
From where was the sample taken?
Occipital region of scalp (preferred) ........................ 1 (b)
Nape / base of neck .................................................. 3 (b)
Other regions of scalp ............................................... 2
SPECIFY: _________________________
b.
Date hair specimen collected:
/
/
M
D
Y
WIHS Form 31: Specimen Collection – 10/01/10
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