HIV Partner Form
Name of Person Filling out Form
First Name
Last Name
Organization of Person Filling out Form
Index Patient Information
*The index patient is the case that the partner is linked to.
Index Patient MIDIS ID
*
Partner Demographics
Date of Session
-
Month
-
Day
Year
Date
Partner Case Open Date
-
Month
-
Day
Year
Date
Partner Date of Birth (If DOB unknown enter 01/01/1800)
*
-
Month
-
Day
Year
Date
Partner Name
*
First Name
Last Name
Partner Contact Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Partner Contact Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Partner Gender Identity
Male
Female
Transgender: Male to Female
Transgender: Female to Male
Another Gender
Declined to Answer
Partner Assigned Sex at Birth
Male
Female
Declined to Answer
Partner Race
American Indian / Alaska Native
Asian
Black or African American
Native Hawaiian / Pacific Islander
White
Don't Know
Not Specified
Declined to Answer
Partner Ethnicity
Hispanic or Latino
Not Hispanic or Latino
Don't Know
Declined to Answer
Date Partner Demographics Collected
-
Month
-
Day
Year
Date
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Partner Enrollment & Disposition
Partner Type:
Sex Partner
Needle-Sharing Partner
Both Sex and Needle-Sharing Partner
Was the partner located?
Located
Unable to Locate
Was enrollment in partner services accepted?
Accepted
Declined
Why was the attempt to locate unsuccessful?
Deceased
Out of Jurisdiction
Other
Is the partner eligible for notification?
Yes - Partner is Notifiable
Yes - Partner is Notifiable & Known to be Previously Positive
No - Partner is Deceased
No - Partner is Out of Jurisdiction
No - Partner Has a Risk of Domestic Violence
No - Partner is Known to be Previously Positive
No - Other
Partner Notification Method
Health Department (Provider) Notification
Client Notification
Dual Notification
Third-Party (e.g., Physician) Notification
Refused Notification
Partner Not Notified
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Partner Risk Profile
Date Risk Profile Collected:
-
Month
-
Day
Year
Date
Did the partner report the following behaviors in the past 12 months?
Rows
Yes
No
Not Asked
Declined to Answer
Vaginal or Anal Sex with a Male
Vaginal or Anal Sex with a Female
Using IV Drugs
Vaginal or Anal Sex without a Condom
Vaginal or Anal Sex with a Transgender Person
Partner Pregnancy Status
Pregnant
Not Pregnant
Partner Housing Status
Unhoused
Unstably House and At-Risk of Losing Housing
Stably Housed
Declined to Answer
Not Asked
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Partner Medical History
Has the partner had a previous HIV test?
Yes
No
Previous HIV Test Result
No Record Found - No Self Report
No Record Found - Self Report Negative
No Record Found - Self Report Positive
Record Found - Negative
Record Found - Positive
Record Found - Preliminary Positive
Record Found - Indeterminate
Did the partner have difficulty getting tested for HIV?
Yes
No
Declined to answer
Other (please specify)
Partner Care Status at Interview
In Care
Not in Care
Pending
Partner Care Agency
Partner Care Site
Has the partner had a previous HCV test?
Yes
No
Previous HCV Test Result
No Record Found - No Self Report
No Record Found - Self Report Negative
No Record Found - Self Report Positive
Record Found - Negative
Record Found - Positive
Record Found - Preliminary Positive
Record Found - Indeterminate
Partner Care Status at Interview
In Care
Not in Care
Pending
Partner Care Agency
Partner Care Site
Partner PrEP Status and Referral
Is the partner currently on PrEP?
Yes
No
Has the partner previously been referred to a PrEP provider?
Yes
No
Partner Declined
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Partner Testing
Was an HIV test performed?
No
No; Partner is known to be HIV Positive
Yes
Date Partner HIV Test Performed:
-
Month
-
Day
Year
Date
HIV Test Type (Select One as a Basis for Determination)
CLIA-waived Point-of-Care (POC) HIV Test
Laboratory-based HIV Test
POC HIV Test Result
Negative
Preliminary Positive
Discordant
Invalid
Laboratory-based HIV Test Result
HIV-1 Negative
HIV-1 Negative; HIV-2 Inconclusive
HIV-1 Positive
HIV-2 Positive
HIV Positive; Undifferentiated
Inconclusive
Was the HIV test result provided to the partner?
Yes
Yes, partner obtained the result from another agency
No
Was the partner counselled about PrEP at the time of testing services?
Yes
No
Partner is currently on PrEP
Was the partner given a referral for PrEP at the time of services?
Yes
No
Partner is currently on PrEP
What is the partner's current HIV medical care status?
No appointment necessary - partner previously positive and engaged in medical care
No appointment necessary - negative test result
Appointment pending
Confirmed - partner accessed service within 14 days of positive test
Confirmed - partner accessed service within 30 days of positive test
Confirmed - partner accessed service after 30 days of positive test
Confirmed - partner did not access service
Partner lost to follow up
Was a test for Syphilis done in conjunction with this HIV test event?
Yes
No
Syphilis Test Result:
Not infected
Newly identified infection
Not known
Was an HCV test performed?
No
No; Partner is known to be HCV Positive
Yes
Date Partner HCV Test Performed:
-
Month
-
Day
Year
Date
HCV Test Type (Select One as a Basis for Determination)
CLIA-waived Point-of-Care (POC) HIV test
Laboratory-based HIV test
POC HCV Test Result
Negative
Preliminary Positive
Discordant
Invalid
Laboratory-based HCV Test Result
Negative
Positive
Inconclusive
Was the HCV test result provided to the partner?
Yes
Yes, partner obtained the result from another agency
No
What is the partner's current HCV medical care status?
No appointment necessary - partner previously positive and engaged in medical care
No appointment necessary - negative test result
Appointment pending
Confirmed - partner accessed service within 14 days of positive test
Confirmed - partner accessed service within 30 days of positive test
Confirmed - partner accessed service after 30 days of positive test
Confirmed - partner did not access service
Partner lost to follow up
Was a test for Syphilis done in conjunction with this HCV test event?
Yes
No
Syphilis Test Result
Not infected
Newly identified infection
Not known
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