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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