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ETHIOPIAN HIV COUNSELING AND TESTING RECORD

ETHIOPIAN HIV COUNSELING AND TESTING RECORD

RECEPTION

Country
Region
Woreda
Site Code

Site type
Circle one
1= Free standing       (NGO based)
2 = Mobile
 
3 = Primary health care
(Hlt Ctr, Hospital)
4 = Clinic
99 = Other

Org type
Circle one
1 = NGO
2 = Gov.
3 = Private

Residence
Circle one
1 = Urban
2 = Rural
9 = Other

Client code
 
Date of visit
 
(dd/mm/yyyy)
Return visit
Circle one
0 = No
1 = Yes

New client code
Circle one
0 = No
1 = Yes
99 = N/A

Age

Sex
Circle one
1 = Male
2 = Female
Counselor code
 
Partner code
 
Couple code

 

PRE-TEST COUNSELING SESSION

Session type
Circle one
1 = Individual
2 = Couple
3 = Group
99 = Other
Marital st.
Circle one
1 = Married
2 = Never married
3 = Separated
4 = Divorced
5 = Widowed
99 = Other
Couple type
Circle one
1 = Married
2 = Premarital
3 = Presextual
4 = Sex partner
98 = N/A
99 = Other
 

Education
Circle one
0 = Illiterate
1 = Able to read
2 = Primary
3 = Secondary
4 = Tertiary
99 = Other
Employed
Circle one
0 = No
(Inactive)
1 = Yes
(Active)

Occupation
Circle one
1 = Legislators, Sr. Officials, Managers
2 = Professionals
3 = Technicians, Ass. Professionals
4 = Clerks
5 = Service, Shop, Market, Sales
 
 
 
6 = Skilled Ag. & Fishery workers
7 = Crafts & trades
8 = Plant/Machine Op., Assembly
9 = Elementary occupation
10 = Students
99 = Other

Hear of our Svcs.
Circle all that apply
1 = Radio
2 = Outreach
3 = Posters
4 = Other clients
5 = Newspaper/magazine
6 = Health institution
7 = Telephone hotline
8 = Anti-ADIS clubs
9 = APLWH/A
10 = Friends and family
11 = CBO
12 = TV
98 = N/A
99 = Other
 
Client referred by:
Circle one.
1 = Self – not referred
2 = Public Health Institution
3 = Private Health Institution
4 = Military Health Institution
5 = Friend or Relative
6 = CBO
7 = NGO
8 = School
9 = Religious Institution
10 = Client
11 = APLWH/A
99 = Other
 
 

Primary reason here
Circle one.
1 = Client Risky/Had risk
2 = Partner Risky/Had risk
3 = Not trust partner
4 = III/Symptoms
5 = Premarital
6 = Marital reunion
7 = Family planning
8 = Visa applicant
9 = Referred
10 = 2nd Test (win.)
11 = Confirm positive result
12 = Get results prev. test
13 = Need counseling
14 = Test before pregnant
 
 
 
15 = Pregnant, must know
16 = Plan for future
17 = Death/illness of partner
18 = Occupational exposure
19 = Other blood/fluid exp.
20 = Sexual assault
99 = Other
Suspected expos. Time
Circle one.
1 = < 1 Month 2 = 1 to 3 months 3 = 4 to 6 months 4 = Over 6 months 98 = N/A Previously tested Circle one 0 = No 1 = Yes, HIV+ 2 = Yes, HIV- 3 = Yes, inconclusive 4 = Result not given 5 = Didn’t take results 99 = Other Date prev. test   ____   ____ Month   Year   Where prev. tested Circle one 1 = NGO 2 = Public health Inst. 3 = Private Health Inst. 98 = N/A 99 = Other Ever had sex Circle one 0 = No 1 = Yes   Condom use last 3 mos. Circle one 0 = Never 1 = Always 2 = Sometimes 98 = N/A   Used condom last sex Circle one 0 = No 1 = Yes 97 = Doesn’t remember 98 = N/A History of STI Circle one 0 = No 1 = Yes 97 = Don’t know No. Casual partners last 6 mos.     No. Steady partners last 6 mos. Is client sex worker? Circle one 0 = No 1 = Yes 2 = Counselor believes so 97 = don’t know 98 = N/A Is client Pregnant? Circle one 0 = No 1 = Yes 97 = Don’t know 98 = N/A Result client expects Circle one 0 = Negative 1 = Positive 97 = Don’t know 98 = N/A Pre-test partner notification plan Circle one 0 = Refused to notify 1 = Agree to notify 2 = Plan to notify 3 = Unsure 98 = N/A   LABORATORY RESULTS HIV result Circle one 0 = Negative 1 = HIV+ 98 = N/A   Syphilis result Circle one 0 = Negative 1 = Positive 95 = Not given   POST-TEST COUNSELING SESSION Couple discordant Circle one 0 = No 1 = Yes 98 = N/A   Refused results Circle one 0 = No 1 = Yes 98 = N/A Condoms accepted Circle one 0 = No 1 = Yes 98 = None available Number condoms given   __________ SERVICES RENDERED                                          Circle one Refused services                       0 = No 1 = Yes   Circle one Counseled                                0 = No 1 = Yes   Circle one Gave test                                   0 = No 1 = Yes   Circle one Received results                     0 = No 1 = Yes   Circle one Referred                                  0 = No 1 = Yes   Circle one Condom demonstration     0 = No 1 = Yes   Other: ____________________________ Risk reduction plan developed Circle one 0 = No 1 = Yes   Post-test partner notification plan Circle one 0 = Refused to notify 1 = Agree to notify 2 = Plan to notify 3 = Unsure 98 = N/A   Client referred to: Circle all that apply 1 = Follow-up counseling 2 = Social services 3 = TB clinic 4 = Hospital 5 = APLWH/A 6 = STD Clinic 7 = Family planning 8 = Post –test club 98 = N/A 99 = Other     Comments:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________   Counselor Signature:  


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