HIV Positive Consumer Served

HIV-Positive Consumer Served

This form is Confidential - Questions? Contact Imagine Hope QA Nurse Tina Gossett, 706.934.5268
Tester Information
Tester's Name

First NameLast Name
Email
example@example.com
Agency
Cell Number
Please enter a valid phone number.Format: (000) 000-0000.
Work Number
Please enter a valid phone number.Format: (000) 000-0000.
City/Town
I served an HIV-positive consumer on:

MonthDayYear
Date
The individual was
Was the individual in need of HIV treatment?

Other
If the individual was in need of HIV treatment, did they receive an appointment?

Other
If the individual was in need of HIV treatment, were you able to confirm that they kept the 1st appointment?

Other
If you were not able to link a client in need of HIV treatment to care, explain why.

Other
Client Information
Year of Birth
Client's Sex

Other
Client's Race

Other
Client's Ethnicity
List the consumer's risk factors (how do they think they contracted HIV?)

Other
Was Partner Notification Initiated?
Drug History
If they report not using drugs or alcohol, input N/A
Drug Use: History (Former Drug Use)

Other
Drug Use: Current

Other
If consumer used/uses Prescription Drugs, list drug names below:
Should be Empty:

HIV-Positive Consumer Served