Kentucky Hiv Test Form
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5PART 1
KENTUCKY HIV TEST FORM
Sample Date
M
M
D
D
Y
Y
Y
Y
M
M
D
D
Y
Y
Y
Y
M
M
D
D
Y
Y
Y
Y
KY Sticker Number
HIV Test 1
HIV Test 2
HIV Test 3
Worker Name
Session Date
□
□
□
Anonymous
Anonymous
Anonymous
M
M
D
D
Y
Y
Y
Y
Test Election
□
□
□
Confidential
Confidential
Confidential
Agency Name
□
□
□
Venipuncture
Venipuncture
Venipuncture
□
□
□
Rapid
Orasure (sent to lab)
Orasure (sent to lab)
(Use L3 Below)
Test Technology
□
□
SURE CHECK (rapid)
SURE CHECK (rapid)
□
□
Agency ID Number
OraQuick (rapid)
OraQuick (rapid)
#
#
#
#
#
□
□
□
Positive/Reactive
Positive/Reactive
Positive/Reactive
□
□
□
Negative
Negative
Negative
□
□
□
Test Result
Indeterminate
Indeterminate
Indeterminate
Client Birth Year
□
□
□
(enter 1800 if unknown)
Invalid
No Result
No Result
Y
Y
Y
Y
□
No Result
□
□
□
No
No
No
Client State
(Answer next question)
(Answer next question)
(Answer next question)
□
□
□
Yes
Yes
Yes
Result Provided
□
□
□
Yes - from another
Yes - from another
Yes - from another
agency
agency
agency
Client County
□
□
□
Declined
Declined
Declined
Notification
Notification
Notification
If Results NOT
□
□
□
Client Zip Code
Did Not Return/
Did Not Return/
Did Not Return/
provided, why?
Could Not Locate
Could Not Locate
Could Not Locate
#
#
#
#
#
□
□
□
Other
Other
Other
Client Ethnicity
□
□
Hispanic or Latino
Don’t Know
Choose status of collection of behavioral risk profile:
□
□
Not Hispanic or Latino
Declined
□
Not Asked
□
□
Client completed behavioral risk profile
Client was asked but no risks identified
□
□
Client Race (check all that apply)
Client was not asked behavioral risk factors
Client declined to discuss risk factors
□
□
American IN/AK Native
White
□
□
Asian
Don’t Know
For clients completing a risk profile, did the client report the following behaviors in the past
□
□
Black/African American
Declined
12 months? (select all that apply)
□
□
Native HI/Pac. Islander
Not Asked
No
Yes
Don’t Know
Client Assigned Sex at Birth
□
□
□
□
□
Male
Declined
Vaginal or anal sex with a MALE
□
□
□
□
□
Female
Not Asked
with a male without using a condom
□
□
□
with a male who is IDU
□
□
□
Client Current Gender Identity
with a male who is HIV+
□
□
Male
Transgender MTF
□
□
□
□
□
Vaginal or anal sex with a FEMALE
Female
Transgender FTM
□
□
□
□
□
Declined
Transgender Unspecified
with a female without using a condom
□
□
□
□
Not Asked
with a female who is IDU
□
□
□
□
with a female who is HIV+
Additional (specify): _______________________________
□
□
□
Vaginal or anal sex with a TRANSGENDER person
Previous HIV Test?
□
□
□
with a transgender without using a condom
□
□
□
□
with a transgender who is IDU
No
□
□
□
□
If Yes, what is the client’s self-reported
Yes
with a transgender who is HIV+
□
Don’t Know
result?
□
Declined
□
□
□
Injection drug use
□
□
Not Asked
Positive
□
□
□
□
□
shared drug injection equipment?
Negative
Don’t Know
□
□
Prelim. Positive
Declined
□
□
□
□
□
Indeterminate
Not Asked
Vaginal or anal sex with MSM (female only)
Additional Risk Factors:
Date of Last Test: __________________
(MM/YYYY)
□
Exchange sex for drugs/money/something they need
□
While intoxicated and/or high on drugs
□
With person of unknown HIV status
□
Local Use Fields:
With person who exchanges sex for drugs/money
□
□
□
With anonymous partner
01 General
02 Targeted (A)
□
□
□
Diagnosed with a sexually transmitted disease (STD)
03 Targeted (B)
04 Targeted DIS
L1 (Testing)
□
□
05 CHTC
Sex with multiple partners
□
Oral sex
□
□
□
Unprotected vaginal/anal sex with a person who is an IDU
L2 (Exposures)
01 Occupational
02 Sexual Assault
□
Unprotected vaginal/anal sex with a person who is HIV+
(Clearview)
□
□
□
□
L3 (Rapid Tests)
Unprotected vaginal/anal sex in exchange for drugs/money/or something they need
01 OraQuick
02 SURE CHECK
03 INSTI
□
Unprotected vaginal/anal sex with person who exchanges sex for drugs/money
□
Use codes from p.2 of
Unprotected sex with multiple partners
L4 (Site Types)
form instructions
#
#
Revised: 10/23/2017 (GCL)
Name of HIV Testing Site (optional): ________________________________________________
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