Imagine Hope HIV Quarterly Report

HIV Screening
Please list staff who provided HIV testing to clients THIS QUARTER (if no tests were done this quarter, put N/A in both fields):*
1. Number of individuals who agreed to an HIV test this quarter:*
2. Of those tested, how many received their results / post test counseling?*
3. Did you EITHER - identify a new HIV+ client - OR serve a previously diagnosed HIV+ client for the first time ?*

YesNo

HIV-Positive
3a How many HIV tests resulted in a preliminary positive result?*
3b. Did you contact Diane Scott, 912.222.5988, to alert her if you had a NEW preliminary HIV+ result?*

YesNo
3c. Number of individuals NEWLY confirmed POSITIVE:*
3d. Number of individuals PREVIOUSLY DIAGNOSED who were re-tested:*
If a preliminary positive is confirmed NEGATIVE, please contact Tina Gossett, 706.934.5268 asap.
3f. Was every preliminary positive confirmed?*

YesNo
3fi. If a HIV preliminary positive result was NOT confirmed, please explain why not.*
3g. Number of NEWLY CONFIRMED HIV+ individuals WHO RECEIVED AN APPOINTMENT for HIV services:*
3h. Number of new HIV+ individuals that you LINKED TO SERVICES - confirmed that they attended 1st appointment.*
3i. Number of PREVIOUSLY DIAGNOSED HIV+ individuals that you served for the first time this quarter:*
3j. Of those (previously diagnosed HIV+ individuals) how many were in need of HIV treatment?*
3k. Of those (previously diagnosed individuals in need of HIV treatment) how many received an appointment for HIV treatment?*
3l. Of those (previously diagnosed individuals referred) how many did you confirm kept the first appointment?*
3m. Did you complete an HIV-Positive Consumer Served Today Form for every HIV+ individual you served for the first time this Quarter?*

YesNo
BEFORE YOU CONTINUE TO THE NEXT SECTION: Please complete an HIV+ Consumer Served form for each HIV+ consumer served for the first time this quarter.

This applies to people you diagnosed this quarter AND to people previously diagnosed that you are serving for the first time this quarter. Please fill out one form for each.

HIV-Positive Consumer Served Form:

https://form.jotform.com/232605379549062

Outreach
4a. Of the total number tested for HIV this quarter, how many were tested at an outreach event?*
4b. How many people did you educate or engage at an outreach event this quarter?*

Reporting
How many HIV bubble sheets (Part 1 and Part 2) did you submit this quarter?*
If no tests were done this quarter, please put a 0.
The total number of HIV bubble sheets does not match the number of HIV tests performed. Please explain why below. *
Please provide us with the tracking number of each Bubble Sheet shipment that were sent to Public Health (if nothing was sent that month, put N/A and 1-1-2000 in the form, form will not let you submit if items are left blank).*
5b.I submitted a Part 3 bubble sheet for every confirmed HIV POSITIVE test performed this quarter*

YesNoN/A

Narrative - your HIV Testing Program

IF A QUESTION DOES NOT APPLY TO YOUR PROGRAM, ENTER N/A.
1. The Full Story

Numbers cannot tell the whole story - we are very interested in your program and we read every word of each report.
1. Tell us about your HIV program this quarter.*
2. Serving HIV+ Individuals
2a. If you were not able to confirm that a newly diagnosed HIV+ client kept their first appointment for HIV treatment, please explain:*
2b. If a self-identified HIV+ client served for the first time this quarter was in need of HIV treatment and you were not able to confirm that they kept their first appointment, please explain:*
2c. Number of HIV+ individuals that you serve on-going:*
2d. Please describe the ongoing support that you provide to HIV+ consumers.*
3. Outreach
3a. Describe any outreach activities. [If your outreach was a part of a campaign (like We>AIDS, or National HIV/AIDS Awareness Day) include the name of the campaign.]*
If you did not do any outreach this quarter, please insert N/A
4. Goals
4a. What are your goals for your HIV testing program?*
4b. What are you doing to reach those goals?*
QUESTIONS? Call Winona Holloway at (404)805-0369

If you do not receive a copy of this report via email, please contact Christina@imaginehope.com.
Should be Empty:

Imagine Hope HIV Quarterly Report

Agency/Tester

HIV Screening

HIV-Positive

If a preliminary positive is confirmed NEGATIVE, please contact Tina Gossett, 706.934.5268 asap.

BEFORE YOU CONTINUE TO THE NEXT SECTION: Please complete an HIV+ Consumer Served form for each HIV+ consumer served for the first time this quarter.

Outreach

Reporting

Narrative - your HIV Testing Program

1. The Full Story

2. Serving HIV+ Individuals

3. Outreach

4. Goals