Kentucky Hiv Test Form Page 4
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5KENTUCKY HIV TEST FORM
p.2
HIV Test Form – Part Two
1. KY Sticker Number
Use a second KY Sticker (duplicate) that corresponds to HIV Test Form Part One to link these two pages
2. Was the client referred to HIV medical care?
Choose one
If “no,” why was the client not referred into care?
Choose one; move on to the next question
If “yes,” did the client attend the first appointment?
Choose one; move on to the next question if “confirmed – accessed service” was not chosen
If “confirmed – accessed service,” did the client attend the appointment within 90 days?
Choose one; move on to the next question
3. Was the client referred to Partner Services?
Choose one
If “yes,” was the client interviewed for partner services?
Choose one; move on to the next question
4. Was the client referred to HIV Prevention Services?
Choose one
If “yes,” did the client receive HIV Prevention Services?
Choose one; move on to the next question
5. What was the client’s housing status in the past 12 months?
Check all that apply
6. If female, is the client pregnant?
Choose one
If “yes,” is the client in prenatal care?
Choose one; move on to the next question
7. Prior to the client testing positive during this testing event, was he/she previously reported to the jurisdiction’s HIV
Surveillance Department as being HIV-positive?
Choose one; move on to the next question
8. Date client reported information for Part Two of HIV Test Form
Enter the date you asked the client the questions on Part Two of the HIV Test Form
9. Has the client ever had a previous positive HIV test?
Choose one
If “yes,” enter a
date.
Enter the date of the client’s last previously positive HIV test
10. Has the client ever had a previous negative HIV test?
Choose one
If “yes,” enter a
date.
Enter the date of the client’s last previously negative HIV test
11. How many negative HIV tests did the client have within 24 months before current (or first positive) HIV test?
Enter number of tests, if known, or choose “Don’t Know” or “Declined”
12. Has client used or is client currently using antiretroviral medication (ARV)?
Choose one
If “yes,” list current medications.
Choose medication codes from the right side of the page
If “yes,” enter a date when ARV began and date of last ARV use.
Enter the dates according to what the client reports
This form is now complete
Additional Risk Factor Codes
01
Exchange sex for drugs/money/or something they needed
02
While intoxicated and/or high on drugs
05
With person of unknown HIV status
06
With person who exchanges sex for drugs/money
08
With anonymous partner
12
Diagnosed with a sexually transmitted disease (STD)
13
Sex with multiple partners
14
Oral sex
Local Use Field L4 (Testing Site Types)
01 Inpatient Hospital
07 Pharmacy/Retail Clinic
12 HIV Testing Site
18 Public Area
02 TB Clinic
08 STD Clinic
13 School/Education Facility
19 Individual Residence
03 Substance Abuse Facility
09 Dental Clinic
14 Church/Religious Facility
20 Other Non-Clinical
04 Community Health Center
10 Correctional Facility
15 Shelter Facility
21 HD – Field Visit
05 Emergency Department
11 Other Clinic
16 Commercial Facility
06 Primary Care Clinic
17 Bar/Club/Adult Entertain.
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