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
Previously diagnosed / self-disclosed HIV+Newly diagnosed HIV+ by me
YesNoOther
YesNoOther
YesNoOther
Lost to follow-up - provided resultLost to follow-up - not provided resultConsumer declined to be linked to treatmentTurned over to DPH for investigation but not confirmed linkedOther
Client Information
Year of Birth*
MaleFemaleTransgender: Male to FemaleTransgender: Female to MaleOther
Black or African AmericanWhiteAsianNative Hawaiian or Pacific IslanderNative American or Alaska NativeOther
Hispanic or LatinoNot Hispanic or Latino
Unprotected receptive anal sexUnprotected receptive vaginal sexShared injection needlesUnprotected insertive anal sexUnprotected insertive vaginal sexShared tattoo needleSexual Assault/RapeUnknownOther
YesNo
Drug History*
If they report not using drugs or alcohol, input N/A
The consumer reports not using drugs or alcoholAlcoholCrack CocaineCocaineCrystal MethamphetamineHeroin or Other OpioidMarijuana/CannabisMushrooms/ShroomsPrescription Drug(s)None - N/AOther
Consumer reports not using drugs or alcoholAlcoholCrack CocaineCocaineCrystal MethamphetamineHeroin / OpioidMarijuana / CannabisMushrooms / ShroomsPrescription Drug(s)None - N/AOther
If consumer used/uses Prescription Drugs, list drug names below:*
Should be Empty:

HIV-Positive Consumer Served

Tester Information

Client Information