GENERAL INSTRUCTIONS FOR COMPLETING THE HIV TEST FORM

• This form is designed to be read by an Optical Character Recognition (OCR) scanner. The legibility of this form depends on
the quality of the hand-written and selected information.
• Carefully separate the sheets at the perforations. If the form tears, it may not be readable by the scanner or operator.
• Each part has a top sheet and a bottom carbonless copy. The top copy (white) is the only sheet that should be scanned. The
bottom copy (yellow) should NOT be scanned; rather it should be used for record keeping purposes.
• DO NOT use red ink. Blue or black ink is preferred.
• DO NOT fold, staple, wrinkle or tear form(s).
• DO NOT USE WHITE OUT. White out sometimes will cause a mis-read by the scanning software.
• DO NOT mark on the bar codes of the Form ID numbers. Marking on the Form ID numbers (barcode) may cause the wrong
number to be scanned.
• DO NOT make any stray marks on the form(s), particularly in the fields where answers will appear.
• Part 1 is the only form with a pre-printed code. You must attach a form identification sticker (barcode) located on the back
of the carbonless copy (yellow) to Part 2 and/or Part 3 in order to link a client’s information.
o Part 1 should be used for all testing events
o Part 2 should be used to record referral data on confirmed HIV positive clients
o Part 3 is used by jurisdictions funded to collect HIV Incidence data.

RESPONSE FORMATS
There are three different response formats on the form that you will use to record data: (1) text boxes, (2) check boxes, and (3)
radio buttons. Instructions for each one of these formats are listed below.

Text boxes
Text boxes are used to record handwritten information (e.g., codes, dates). When writing letters or numbers in the boxes:
• use all capital letters and write neatly in your best penmanship. DO NOT use cursive.
• put only 1 letter or number per box and DO NOT have any part of the letter or number touch the edges of the box.

Here are examples of how to write letters and numbers:

LETTERS

NUMBERS

Check boxes
Check boxes are used to select all options that apply. For example, check boxes are used to record information about “Race.”
• use an “X” instead of a check mark because the tail of the check mark might run over into another box.
• keep the “X” within the edges of the box.

Radio buttons
Radio buttons are ovals used to select only one option from among two or more options. For example, radio buttons are used to select
“Current Gender.” When selecting an option using a radio button:
• fill in the oval completely.
• DO NOT mark over area of the oval.
 HIV TEST FORM
Code 128 PART 1
0000000000 Form Approved: OMB No. 0920-0696, Exp. Date: 08/31/2010
Session Date (MMDDYYYY) Unique Agency ID Number Intervention ID
Agency

MMDD

Site ID Site Type . Intervention ID

Site Zip Code
(See codes on reverse)
Client ID Date of Birth (MMDDYYYY) State County Zip Code

Race – Check all that apply

L
Ethnicity Current Gender Previous HIV Test? Self-Reported Result
Hispanic or Latino American Ind./AK Native Male Yes Positive Indeterminate
Client

Not Hispanic or Latino Female No Negative Don’t know

Asian
Don’t know Transgender – M2F Don’t know Prelim. Pos. Declined
Declined Black/African American Transgender – F2M Declined Not asked L
Native HI/Pac. Islander Not asked Provide date of last test (MMYYYY)
L

White
Don’t know Declined

Sample Date
(MMDDYYYY)

Worker ID

Tested anonymously Tested anonymously Tested anonymously

Source
Test Election Tested confidentially Tested confidentially Tested confidentially
Declined testing Declined testing Declined testing

Test Conventional Conventional Conventional

Technology Rapid HIV TEST 1 Rapid HIV TEST 2 Rapid HIV TEST 3
Other Other Other
HIV Test Information

Specimen Blood: finger stick Blood: finger stick Blood: finger stick
Type Blood: venipuncture Blood: venipuncture Blood: venipuncture
Blood spot Blood spot Blood spot
L

Oral mucosal transudate Oral mucosal transudate Oral mucosal transudate

Urine Urine Urine
Housing Status in the Past 3 months –
Positive/Reactive Indeterminate Positive/Reactive Check all that apply
Indeterminate Positive/Reactive Indeterminate
Test Result
NAAT-pos Invalid NAAT-pos Invalid NAAT-pos Invalid
Negative No result Negative No result Negative No result
Result
Provided Yes No Yes No Yes No

Date Provided
(MMDDYYYY)

If results not Declined notification Declined notification Declined notification

provided, Did not return/Could not locate Did not return/Could not locate Did not return/Could not locate
why? Obtained results from another agency Obtained results from another agency Obtained results from another agency
If rapid Yes Yes Yes
reactive, did Client declined confirmatory test Client declined confirmatory test Client declined confirmatory test
client provide Did not return/Could not locate Did not return/Could not locate Did not return/Could not locate
confirmatory Referred to another agency Referred to another agency Referred to another agency
sample? Other Other Other

Choose one if: Client was not asked about risk factors Client was asked, but no risk was identified Client declined to discuss risk factors
Risk Factors

If client risk factor information was discussed, please mark all that apply:
L

In past 12 months has client had: ...without using a condom? Injection Drug Use (IDU) Other Risk Factor(s)

Vaginal or Anal Sex Oral Sex ...with person who is an IDU? Has client used injection drugs in
past 12 months?
if marked
With Male ...with person who is MSM? (Female
Only)
Did client share drug injection
With Female L ...with person who is HIV positive?
equipment?
(see codes on reverse)

Session Activity Local Use Fields CDC Use Fields

During this visit, was a risk reduction plan developed
Yes No
for the client? L1 C1
Other Session Activities (see codes on reverse)

. . L2
C2

Public reporting burden of this collection of information is estimated to average 8 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data
needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB
Control Number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600
Clifton Road NE, MS D-79, Atlanta, Georgia 30333; ATTN: PRA 0920-0696. CDC 50.135a (E), 10/2007
WHITE COPY = Scan YELLOW COPY = Record Keeping
 Code 128
HIV TEST FORM
0000000000
PART 1
Form Approved: OMB No. 0920-0696, Exp. Date: 08/31/2010
Session Date (MMDDYYYY) Unique Agency ID Number Intervention ID
Agency

MMDD

Site ID Site Type . Intervention ID

Site Zip Code
(See codes on reverse)
Client ID Date of Birth (MMDDYYYY) State County Zip Code

Race – Check all that apply

L
Ethnicity Current Gender Previous HIV Test? Self-Reported Result
Hispanic or Latino American Ind./AK Native Male Yes Positive Indeterminate
Client

Not Hispanic or Latino Female No Negative Don’t know

Asian
Don’t know Transgender – M2F Don’t know Prelim. Pos. Declined
Declined Black/African American Transgender – F2M Declined Not asked L
Native HI/Pac. Islander Not asked Provide date of last test (MMYYYY)
L

White
Don’t know Declined

Sample Date
(MMDDYYYY)

Worker ID

Tested anonymously Tested anonymously Tested anonymously

Source
Test Election Tested confidentially Tested confidentially Tested confidentially
Declined testing Declined testing Declined testing

Test Conventional Conventional Conventional

Technology Rapid HIV TEST 1 Rapid HIV TEST 2 Rapid HIV TEST 3
Other Other Other
HIV Test Information

Specimen Blood: finger stick Blood: finger stick Blood: finger stick
Type Blood: venipuncture Blood: venipuncture Blood: venipuncture
Blood spot Blood spot Blood spot
L

Oral mucosal transudate Oral mucosal transudate Oral mucosal transudate

Urine Urine Urine
Housing Status in the Past 3 months –
Positive/Reactive Indeterminate Positive/Reactive Check all that apply
Indeterminate Positive/Reactive Indeterminate
Test Result
NAAT-pos Invalid NAAT-pos Invalid NAAT-pos Invalid
Negative No result Negative No result Negative No result
Result
Provided Yes No Yes No Yes No

Date Provided
(MMDDYYYY)

If results not Declined notification Declined notification Declined notification

provided, Did not return/Could not locate Did not return/Could not locate Did not return/Could not locate
why? Obtained results from another agency Obtained results from another agency Obtained results from another agency
If rapid Yes Yes Yes
reactive, did Client declined confirmatory test Client declined confirmatory test Client declined confirmatory test
client provide Did not return/Could not locate Did not return/Could not locate Did not return/Could not locate
confirmatory Referred to another agency Referred to another agency Referred to another agency
sample? Other Other Other

Choose one if: Client was not asked about risk factors Client was asked, but no risk was identified Client declined to discuss risk factors
Risk Factors

If client risk factor information was discussed, please mark all that apply:
L

In past 12 months has client had: ...without using a condom? Injection Drug Use (IDU) Other Risk Factor(s)

Vaginal or Anal Sex Oral Sex ...with person who is an IDU? Has client used injection drugs in
past 12 months?
if marked
With Male ...with person who is MSM? (Female
Only)
Did client share drug injection
With Female L ...with person who is HIV positive?
equipment?
(see codes on reverse)

Session Activity Local Use Fields CDC Use Fields

During this visit, was a risk reduction plan developed
Yes No
for the client? L1 C1
Other Session Activities (see codes on reverse)

. . L2
C2

Public reporting burden of this collection of information is estimated to average 8 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data
needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB
Control Number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600
Clifton Road NE, MS D-79, Atlanta, Georgia 30333; ATTN: PRA 0920-0696. CDC 50.135a (E), 10/2007
WHITE COPY = Scan YELLOW COPY = Record Keeping
 Client Identifying Data (Optional)

Name: _______________________________________________________________________________________________________________________

Address:______________________________________________________________________________________________________________________

Phone: ___________________________________ Other: ____________________________________________________________________________

Codes for Site Type F02.99 Outpatient Facility- Unknown

F01 Inpatient Facility F03 Emergency Room
F01.01 Inpatient Hospital F04.01 Blood Bank, Plasma Center
F01.50 Inpatient- Drug / Alcohol Treatment F04.05 HIV Counseling and Testing Site
F01.88 In patient Facility- Other F06 Community Setting
F01.99 Inpatient Facility- Unknown F06.01 Community Setting – AIDS Service Organization – non clinical
F02 Outpatient facility F06.02 Community Setting – School/Education Facility
F02.03 Outpatient- Private Medical Practice F06.03 Community Setting – Church/Mosque/Synagogue/Temple
F02.04 Outpatient- HIV Specialty Clinic F06.04 Community Setting – Shelter/Transitional housing
F02.10 Outpatient- Prenatal/ OBGYN Clinic F06.05 Community Setting – Commercial
F02.12 Outpatient- TB Clinic F06.06 Community Setting – Residential
F02.19 Outpatient- Drug / Alcohol Treatment Clinic F06.07 Community Setting – Bar/Club/Adult Entertainment
F02.20 Outpatient- Family Planning F06.08 Community Setting – Public Area
F02.30 Outpatient- Community Mental Health F06.09 Community Setting – Workplace
F02.51 Outpatient- Community Health Clinic F06.12 Individual Residence
F02.58 Outpatient- School/University Clinic F06.10 Community Setting – Community Center
F02.60 Outpatient- Health Department/Public Health Clinic F06.88 Community Setting – Other
F02.61 Outpatient- Health Department/Public Health Clinic-HIV F07 Correctional Facility
F02.62 Outpatient- Health Department/Public Health Clinic-STD F88 Facility – Other
F02.88 Outpatient Facility- Other
Codes for Other Risk factor(s)
01 Exchange sex for drugs/money/or something they need
02 While intoxicated and/or high on drugs
05 With person of unknown HIV status
06 With person who exchanges sex for drugs/money
08 With anonymous partner
09 With person who has hemophilia or transfusion/transplant recipient
11 Sex with transgender
Codes for Other Session Activities
01.00 Not Collected
03.00 HIV Testing 10.07 Practice – Partner notification
04.00 Referral 10.88 Practice – Other
05.00 Personalized Risk assessment 11.01 Discussion – Sexual risk reduction
06.00 Elicit Partners 11.02 Discussion – IDU risk reduction
07.00 Notification of exposure 11.03 Discussion – HIV testing
08.01 Information – HIV/AIDS transmission 11.04 Discussion – Other sexually transmitted diseases
08.02 Information-Abstinence/postpone sexual activity 11.05 Discussion – Disclosure of HIV status
08.03 Information-Other sexually transmitted diseases 11.06 Discussion – Partner notification
08.04 Information-Viral hepatitis 11.07 Discussion – HIV medication therapy adherence
08.05 Information – Availability of HIV/STD counseling and testing 11.08 Discussion – Abstinence/postpone sexual activity
08.06 Information-Availability of partner notification and referral 11.09 Discussion – IDU risk free behavior
services 11.10 Discussion – HIV/AIDS transmission
08.07 Information – Living with HIV/AIDS 11.11 Discussion – Viral hepatitis
08.08 Information – Availability of social services 11.12 Discussion – Living with HIV/AIDS
08.09 Information – Availability of medical services 11.13 Discussion – Availability of HIV/AIDS counseling testing
08.10 Information – Sexual risk reduction 11.14 Discussion – Availability of partner notification and referral
08.11 Information – IDU risk reduction services
08.12 Information – IDU risk free behavior 11.15 Discussion – Availability of social services
08.13 Information – Condom/barrier use 11.16 Discussion – Availability of medical services
08.14 Information – Negotiation / Communication 11.17 Discussion – Condom/barrier use
08.15 Information – Decision making 11.18 Discussion – Negotiation / Communication
08.16 Information – Disclosure of HIV status 11.19 Discussion – Decision making
08.17 Information – Providing prevention services 11.20 Discussion – Providing prevention services
08.18 Information – HIV testing 11.21 Discussion – Alcohol and drug use prevention
08.19 Information – Partner notification 11.22 Discussion – Sexual health
08.20 Information – HIV medication therapy adherence 11.23 Discussion – TB testing
08.21 Information – Alcohol and drug use prevention 11.24 Discussion – Stage Based Encounter
08.22 Information – Sexual health 11.88 Discussion – Other
08.23 Information – TB testing 12.01 Other testing – Pregnancy
08.66 Information – Other 12.02 Other testing – STD
09.01 Demonstration – Condom/barrier use 12.03 Other testing – Viral hepatitis
09.02 Demonstration – IDU risk reduction 12.04 Other testing – TB
09.03 Demonstration – Negotiation / Communication 13.01 Distribution – Male condoms
09.04 Demonstration – Decision making 13.02 Distribution – Female condoms
09.05 Demonstration – Disclosure of HIV status 13.03 Distribution – Safe sex kits
09.06 Demonstration – Providing prevention services 13.04 Distribution – Safer injection / bleach kits
09.07 Demonstration – Partner notification 13.05 Distribution – Lubricants
09.88 Demonstration – Other 13.06 Distribution – Education materials
10.01 Practice – Condom/barrier use 13.07 Distribution – Referral lists
10.02 Practice – IDU risk reduction 13.08 Distribution – Role model stories
10.03 Practice – Negotiation / Communication 13.09 Distribution – Dental DAMS
10.04 Practice – Decision making 13.88 Distribution – Other
10.05 Practice – Disclosure of HIV status 14.01 Post-intervention follow up
10.06 Practice – Providing prevention services 14.02 Post-intervention booster session
15.00 HIV Testing History Survey
89 Other

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