Download PwP Client Level Demographic-Risk Info

Prevention with Positives Client Level
DEMOGRAPHIC AND RISK PROFILE DATA COLLECTION TOOL
 These are the data variables that you are required to collect and enter into EvaluationWeb for every client who participates in
any and all PwP interventions (ILI, GLI, IRRC, PCM).
 Collect this information for each client who is HIV positive.
 Collect this information for each client who is the sexual and/or needle sharing partner of a person who is HIV positive.
 You are not required to use or submit this tool. You may develop your own data collection tool.
For agency use only. Client names are not
entered into EvaluationWeb or reported to CDC.
1. Client Name:
2. Client ID:
Must be an ID that is unique to this client. Cannot contain any personally identifying info.
DEMOGRAPHIC DATA
3. Date Demographic Data Collected:
4. Year of Birth (if unknown, enter 1800):
5. Country of Birth:
6. State of Residence:
8. Ethnicity:
Hispanic or Latino
Not Hispanic or Latino
Don’t Know
Declined to Answer
Not Asked
10. Assigned Sex at Birth:
Male
Female
Not Asked
Declined to Answer
7. County of Residence:
9. Race (select all that apply):
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Pacific Islander
White
Declined to Answer
Don’t Know
Not Asked
11. Current Gender:
Male
Female
Transgender - MTF
Transgender - FTM
Transgender - Unspecified
Not asked
Declined to answer
Other, please specify:
RISK PROFILE
Date of the initial risk profile should be the intake date or first session. Additional risk
profiles can be added at any time with a new date.
12. Date Risk Data Collected:
13. Previous HIV Test:
No
Yes
Not Asked
Declined to Answer
Don’t Know
If Yes, continue to 14.
Any other response,
skip to 15.
15. Client Behavioral Risk Profile:
Client completed risk profile
Client was not asked about risk factors
No risk identified
Client declined to discuss risk factors
14. Self-Reported Result of Most Recent HIV Test:
Positive
Negative
Preliminary Positive
Indeterminate
Not Asked
Declined to Answer
Don’t Know
If client completed risk profile, continue to 16.
Any other response, you do not need to complete
any further questions on this form.
RISK PROFILE, continued
Indicate whether or not the client self-reported any of the following risk behaviors in the past 12 months.
16. Vaginal or anal sex with a male
If Yes, also respond to the following:
Vaginal or anal sex without a condom with a male
Vaginal or anal sex with a male IDU
Vaginal or anal sex with HIV positive male
Vaginal or anal sex with MSM
Yes
No
Don’t Know
Declined to Answer
Not Asked
Yes
Yes
Yes
No
No
No
Don’t Know
Don’t Know
Don’t Know
Declined to Answer
Declined to Answer
Declined to Answer
Not Asked
Not Asked
Not Asked
Yes
No
Don’t Know
Declined to Answer
Not Asked
17. Vaginal or anal sex with a female
If Yes, also respond to the following:
Vaginal or anal sex without a condom with a female
Vaginal or anal sex with a female IDU
Vaginal or anal sex with HIV positive female
Yes
No
Don’t Know
Declined to Answer
Not Asked
Yes
Yes
Yes
No
No
No
Don’t Know
Don’t Know
Don’t Know
Declined to Answer
Declined to Answer
Declined to Answer
Not Asked
Not Asked
Not Asked
18. Vaginal or anal sex with a transgender person
If Yes, also respond to the following:
Vaginal or anal sex without a condom with a
transgender person
Vaginal or anal sex with a transgender IDU
Vaginal or anal sex with an HIV positive
transgender person
Yes
No
Don’t Know
Declined to Answer
Not Asked
Yes
No
Don’t Know
Declined to Answer
Not Asked
Yes
No
Don’t Know
Declined to Answer
Not Asked
Yes
No
Don’t Know
Declined to Answer
Not Asked
19. Injection drug use
If yes, also respond to the following:
Share drug injection equipment
Yes
No
Don’t Know
Declined to Answer
Not Asked
Yes
No
Don’t Know
Declined to Answer
Not Asked
(only for clients whose current gender is female or MTF)
20. Additional Risk Factors
If the client’s risk in the past 12 months involves anal or vaginal sexual activity, indicate whether the client also engaged in any of
the following risk factors (select all that apply):
Exchange sex for drugs, money or something they needed
Diagnosed with sexually transmitted disease (STD)
Sex with multiple partners
Oral sex
Unprotected vaginal or anal sex with a person who is an IDU
Unprotected vaginal or anal sex with a person who is HIV positive
Unprotected vaginal or anal sex in exchange for drugs, money or something they needed
Unprotected vaginal or anal sex with person who exchanges sex for drugs or money
Unprotected sex with multiple partners
Sex while intoxicated or high on drugs
Sex with person of unknown HIV status
Sex with person who exchanges sex for drugs or money
If client’s risk did not involve anal or
vaginal sexual activity, do not
complete this question.