HIV Index Case Form

HIV Index Case Form
Index Patient Info
Date of Session

MonthDayYear
Date
MIDIS Index Patient ID:
Index Patient Name:*

First NameLast Name
Index Patient Date of Birth*

MonthDayYear
Date
Index Patient Enrollment & Disposition
Attempt to Locate Index Patient:

LocatedUnable to Locate
Partner Services:

The patient consents to an interview to provide details about their partners, who can then be discreetly informed about their potential exposure or risk. Additional partner services might include prevention counseling, testing for other STIs, hepatitis screening and vaccination, connection to medical care, and referrals to other necessay services, such as mental health care, substance use treatment, social support, housing assistance, and legal services.

Partner services must remain confidential, voluntary, non-coercive, and free of charge.
Was enrollment in partner services accepted?

AcceptedDeclined
Why was the attempt to locate the index patient unsuccessful?

Out of JurisdictionDeceasedOther (please specify)

Partner Elicitation
Total number of CLAIMED Sex and/or Needle-Sharing partners within the last 12 months:
Total number of NAMED Sex and/or Needle-Sharing partners within the last 12 months:
Should be Empty:

	Yes	No	Not Asked	Declined to Answer
Injection Drug Use
Vaginal or Anal Sex with a Male
Vaginal or Anal Sex with a Female
Vaginal or Anal Sex with a Transgender Person
Vaginal or Anal Sex without a Condom

Index Patient Info