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Linking our client to Care-CTR (900) Form
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Ryan White ROI
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Assigned to:
01-Ryan White Part B/ 02-Ryan White Part-B MAI/03-Ryan White Part A (Regional EIS)/04-Ryan White Part A-MAI (Youth)/ 05-CHT/06-Clinical Testing/07-Pharmacy Testing/08-CHARLII/09-ASE/10-SNSN/11-Harm Reduction/12-if Other specify name of the program.
Intake Assessment WP form #:
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1-PROGRAM ANNOUNCEMENT NUMBER
Select
PS18-1802
PS15-1502-Category B
PS17-1711
PS19-1901 CDC STD
PS21-2102
Other
1.1-if you answered other:
2-VDH GRANT PROGRAM
Select
CHT
Clinical Testing
Pharmacy Testing
CHARLII
ASE
SNSN
Harm Reduction
Other
2.1-If you answered other:
AGENCY
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3-Session Date
5-Site Zip Code
7-If Site Type is other, please specify
Select
Family Planning
Maternal/OB
General Medical
Refugee
Other
4-Unique Agency ID Number:
Select
17675
6-Site Type
Select
F04.05 non-Clinical-HIV testing site
F06.02 non-Clinical-Community Setting -School/Educational Facility
F06.03 non-Clinical-Community Setting -Church/Mosque/Synagogue/Temple
F06.04 non-Clinical-Community Setting - Shelter/Transitional Housing
F06.05 non-Clinical-Community Setting -Commercial Facility
F06.07 non-Clinical-Community Setting Bar/Club/Adult Entertainment
F06.08 non-Clinical-Community Setting-Public Area
F02.19 Clinical-Substance Abuse Treatment Facility
F06.12 non-Clinical-Community Setting-Individual Residence
F06.88 non-Clinical-Community Setting-Other
F07 non-Clinical-Correctional Facility/non-Healthcare
F14 non-Clinical-Health Department-Field Visit
F15 non-Clinical-Community Setting-Syringe Exchange Program
F40 non-Clinical-Mobile Unit
F50 non-Clinical-Self Testing
F88 non-Clinical Other
F01.01 Clinical-Impatient Hospital
F02.12 Clinical-TB Clinic
F02.51 Clinical-Community Health Center
F03 Clinical-Emergency Department
F08 Clinical Primary Care Clinic (Other than CHC)
F09 Clinical-Pharmacy or other related-based clinic
F10 Clinical-STD Clinic
F11 Clinical-Dental Clinic
F12 Clinical-Correctional Facility Clinic
F13 Clinical-Other
7.1-If you answered other:
CLIENT
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9-Client ID (12-digit code):
11-State:
Select
VA-Virginia
MD-Maryland
DC-District of Columbia
13-Client's County or Independent City:
15-Race:
Select
American Indian/Alaskan Native
Asian
Black/African American
Native Hawaiian/Pacific Islander
White
Declined
Don't Know
Not Specified
17-Current Gender:
Select
Male
Female
Transgender-F2M
Transgender-M2F
Trans-unspecified
Declined
Another Gender
10-Year of Birth (XXXX)
12-Zip Code (XXXXX):
14-Ethnicity:
Select
Hispanic or Latino
Non-Hispanic or Latino
Don;t Know
Declined
16-Sex at Birth:
Select
Male
Female
Declined
18-Previous Test:
Select
Yes
No
Don't Know
TEST INFORMATION
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19-Test 1 Sample Date
19.1-Test 1 Worker ID
Select
AHILL
AAERTS
ASEYMORE
GMARIUS
IAGUIRRE
OFLORES
RMCCOY
SAMPUERO
SPORTILLO
SGONZALEZ
VTOVAR
19.2-Test 1 Technology
Select
Fingerstick Rapid
Lab-Based Test
Determine
INSTI
Other
19.3-Test 1 Result
Select
Rapid Prelim-Positive
Rapid-Positive
Rapid-Negative
Rapid-Discordant
Rapid-Invalid
Lab-Based - HIV Negative
Lab-Based - HIV-1 Positive
Lab-Based - HIV-2 Positive
Lab-Based - Inconclusive
19.4-Test 1 Result Provided
Select
Yes
No
Yes, the client obtained result from another agency
19.5-Test 1 Was this the last test?
Select
Yes, this was the last test performed
No, this was not the last test provided
20-Test 2 Sample Date
20.1-Test 2 Worker ID
Select
AHILL
AAERTS
ASEYMORE
GMARIUS
IAGUIRRE
OFLORES
RMCCOY
SAMPUERO
SPORTILLO
SGONZALEZ
VTOVAR
20.2-Test 2 Technology
Select
Fingerstick Rapid
Lab-Based Test
Determine
INSTI
Other
20.3-Test 2 Result
Select
Rapid Prelim-Positive
Rapid-Positive
Rapid-Negative
Rapid-Discordant
Rapid-Invalid
Lab-Based - HIV Negative
Lab-Based - HIV-1 Positive
Lab-Based - HIV-2 Positive
Lab-Based - Inconclusive
20.4-Test 2 Result Provided
Select
Yes
No
Yes, the client obtained result from another agency
20.5-Test 1 Was this the last test?
Select
Yes, this was the last test performed
No, this was not the last test provided
21-Test 3 Sample Date
21.1-Test 3 Worker ID
Select
AHILL
AAERTS
ASEYMORE
GMARIUS
IAGUIRRE
OFLORES
RMCCOY
SAMPUERO
SPORTILLO
SGONZALEZ
VTOVAR
21.2-Test 3 Technology
Select
Fingerstick Rapid
Lab-Based Test
Determine
INSTI
Other
21.3-Test 3 Result
Select
Rapid Prelim-Positive
Rapid-Positive
Rapid-Negative
Rapid-Discordant
Rapid-Invalid
Lab-Based - HIV Negative
Lab-Based - HIV-1 Positive
Lab-Based - HIV-2 Positive
Lab-Based - Inconclusive
21.4-Test 3 Result Provided
Select
Yes
No
Yes, the client obtained result from another agency
21.5-Test 3 Was this the last test?
Select
Yes, this was the last test performed
No, this was not the last test provided
Other Tests
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22-Client tested for co-infections?
Select
Yes
No
23-If Yes, mark the co-infections for which the client was tested:
Syphillis
Chlamydia
Gonorrhea
Hepatitis A
Hepatitis B
Hepatitis C
BELOW THIS LINE REQUIRED ONLY FOR STI CLINIC & NON-CLINICAL TESTING
RISK PROFILE AND SERVICE NEEDS
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24-Client Received Risk Assessment
Select
Yes
No
26-Was the client screened for PrEP eligibility?
Select
Yes
No
28-Was the client referred to PrEP provider?
Select
Yes
No
30-PrEP Awareness and Use:
Client has ever heard of PrEP
Client currently taking PrEP
Client used PrEP in the past 12 months
25-Client is at risk of HIV:
Select
Yes
No
Risk not known
27-Is the client eligible for PrEP referral?
Select
Yes, by CDC criteria
Yes, by DDP criteria
No
29-Was the client provided PrEP navigation?
Select
Yes
No
31-In the last 5 years, client has:
Had sex with male
Has sex with female
Injected drugs/substances
Had sex with an HIV+ person
Participated in sex work
OTHER SERVICE NEEDS
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30-Health Benefits Enrollment
Screened
Need Identified
Referred or Provided
32-Behavioral Health Services
Screened
Need Identified
Referred or Provided
31-Risk Reduction Intervention
Screened
Need Identified
Referred or Provided
33-Other Social Services
Screened
Need Identified
Referred or Provided
Local Use Fields (32 characters max)
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L6:
L7:
Notes
Write your notes:
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