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.
Work Number*
Please enter a valid phone number.
City/Town*
I served an HIV-positive consumer on:*

MonthDayYear
Date
The individual was*

Previously diagnosed / self-disclosed HIV+Newly diagnosed HIV+ by me
Was the individual in need of HIV treatment?

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

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

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

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*
Client's Sex*

MaleFemaleTransgender: Male to FemaleTransgender: Female to MaleOther
Client's Race*

Black or African AmericanWhiteAsianNative Hawaiian or Pacific IslanderNative American or Alaska NativeOther
Client's Ethnicity*

Hispanic or LatinoNot Hispanic or Latino
List the consumer's risk factors (how do they think they contracted HIV?)*

Unprotected receptive anal sexUnprotected receptive vaginal sexShared injection needlesUnprotected insertive anal sexUnprotected insertive vaginal sexShared tattoo needleSexual Assault/RapeUnknownOther
Was Partner Notification Initiated?*

YesNo
Drug History*
If they report not using drugs or alcohol, input N/A
Drug Use: History (Former Drug Use)*

The consumer reports not using drugs or alcoholAlcoholCrack CocaineCocaineCrystal MethamphetamineHeroin or Other OpioidMarijuana/CannabisMushrooms/ShroomsPrescription Drug(s)None - N/AOther
Drug Use: Current

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