Kentucky Hiv Test Form (Page 3 of 5) in pdf

KENTUCKY HIV TEST FORM

p.1

General Instructions

1. Use a blue or black ink pen to complete this form.

2. Please print your responses legibly. Unclear and incomplete forms will be sent back to your agency to be fixed.

□

3. Multiple choice boxes (

) should be clearly marked with a “X” only.

4. Part one of the HIV test form should be completed for everyone who receives a HIV test. Part two of the HIV test form

should be completed for everyone confirmed HIV-positive (by Kentucky Division of Laboratory Services, Western Blot,

IFA or “Rapid-Rapid” protocol).

5. There are no preprinted Form ID or Client ID numbers. You must adhere or write in the form identification (KY Sticker)

number on Part one and, when applicable, Part two of the HIV test form. Do not create your own sticker numbers—

these must be obtained from the state HIV/AIDS Branch.

6. To order more KY numbered stickers, call or e-mail Kay.Loftus@ky.gov

7. Mail* completed forms for the current month by the 15

of the following month** to:

CHFS - HIV/AIDS Branch

Attn: Kay Loftus

275 E. Main St., HS2E-C

Frankfort, KY 40621-0001

8. Newly infected HIV cases, confirmed by Kentucky Division of Laboratory Services, Western Blot, IFA or “Rapid-Rapid”

protocol, are to be reported to HIV Surveillance within 5 business days. Reactive results on a Rapid Test are not

reportable until they have been confirmed. (see p.3 for more info)

9. Blank HIV test forms and HIV reportable disease forms can be obtained at

10. If you have questions or general concerns, please contact us at 800-420-7431

*Agencies completing direct data entry (DDE) into the EvaluationWeb online system should enter data into the system by

the 15

of the following month. Forms entered in this fashion should not be mailed to the HIV/AIDS Branch. Instead, keep

your entered test forms for one year from the date of the test or in accordance to your agency’s record retention policies,

whichever time frame is longer. Records ready for expunging should follow HIPAA guidelines for disposal.

**The exception to this rule is if you have a confirmed HIV-positive client, it may take up to 90 days to complete part two of

the HIV test form. Part one and part two must be completed and sent in together.

HIV Test Form – Part One

Left-side column:

Right-side column:

1. KY Sticker Number

1. Sample Date

Use KY Sticker as the Form ID

Date of the HIV test

2. Session Date

2. Worker Name

Date of the HIV test

Enter first name and last initial of the tester

3. Agency Name

3. Test Election

Write out your agency name

Choose one

4. Agency ID Number

4. Test Technology

Use your assigned agency number

Choose one

5. Test Result

5. Client’s Birth Year

Choose one

Four digit number. If unknown, enter 1800.

6. Result Provided

6. Client’s State

Choose one

The state in which the client resides (see p.3)

7. If result not provided, why?

7. Client’s County

If applicable, choose one

The county in which the client resides

8. Client’s Zip Code

8. Choose One [Risk Profile]

The zip code in which the client resides

Choose one

9. Table [Client Identified Risks]

9. Client Ethnicity

Choose all that apply

Choose one

10. Additional Risk Factors

10. Client Race

Choose all that apply

11. Client Assigned Sex at Birth

11. Name of HIV Testing Site

Choose one

Optional, enter where test took place

12. Client Current Gender Identity

Choose one or enter additional identity

13. Previous HIV Test

Two “Rapid-Rapid” Protocols are Available:

Choose one; if “yes,” indicate previous result and

date of last test (if known)

1. Begin with INSTI, follow up positives

with SURE CHECK or OraQuick

14. Local Use Fields

For fields L1 – L3, choose one

2. Begin with SURE CHECK, follow up

For field L4, use codes from p.2

positives with OraQuick

Kentucky Hiv Test Form Page 3

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