![](media/image1.jpeg){width="3.498425196850394in"
height="2.866535433070866in"}

*A Community-Based Strategy for Identifying Persons with*

*Undiagnosed HIV Infection*

*Data Collection Forms*

![](media/image2.jpeg){width="1.08125in" height="0.8298611111111112in"}

[TABLE OF CONTENTS]{.underline}

[SECTION ONE: OVERVIEW 3](#section-one-overview)

[SECTION TWO: RECRUITER ENLISTMENT/ORIENTATION LOG
4](#section-two-recruiter-enlistmentorientation-log)

[Field descriptions 5](#field-descriptions)

[Example 7](#example)

[SECTION THREE: PARTICIPANT REGISTRATION FORM
8](#section-three-participant-registration-form)

[Field descriptions 9](#field-descriptions-1)

[Example 11](#example-1)

[SECTION FOUR: PARTICIPANT DATA FORM
12](#section-four-participant-data-form)

[General Information Page (All Participants)
13](#general-information-page-all-participants)

[Field descriptions 13](#field-descriptions-2)

[Example 16](#example-2)

[Testing History Page (All Participants)
17](#testing-history-page-all-participants)

[Field descriptions 17](#field-descriptions-3)

[Example 19](#example-3)

[Interview Page (Recruiters Only) 20](#interview-page-recruiters-only)

[Interview Page (Network Associates)
20](#interview-page-network-associates)

[Field descriptions 20](#field-descriptions-4)

[Example 23](#example-4)

[Interview Page (General Recruiter Issues)
24](#interview-page-general-recruiter-issues)

[Field descriptions 24](#field-descriptions-5)

[Example 25](#example-5)

[Recruitment Method Page (Associates Only)
26](#recruitment-method-page-associates-only)

[Field descriptions 26](#field-descriptions-6)

[Example #1 28](#example-1-1)

[Example #2 29](#example-2-1)

[CTR Information Page (For Any Participant Tested)
30](#ctr-information-page-for-any-participant-tested)

[Field descriptions 30](#field-descriptions-7)

[Example 36](#example-6)

[Notes Page (All Participants) 41](#notes-page-all-participants)

[Field descriptions 41](#field-descriptions-8)

[Example 42](#example-7)

[SECTION FIVE: BLANK DATA COLLECTION FORMS
43](#section-five-blank-data-collection-forms)

# SECTION ONE: OVERVIEW

*[Purpose of this document]{.underline}*

This document provides instructions for using each of the social
networks testing data collection forms. Descriptions of fields are
provided, along with examples. Blank forms that can be modified to fit
your program are provided in the last section.

# SECTION TWO: RECRUITER ENLISTMENT/ORIENTATION LOG

[Purpose]{.underline}

> The Recruiter Enlistment/Orientation Log is designed to document
> information about the individuals who are invited to be recruiters in
> the social networks testing program.

[Description]{.underline}

> This log will track:

-   Individuals who have been screened for recruiter eligibility

-   Individuals who have previously been a network associate

-   When people were invited to be recruiters and when they enlisted in
    program

-   Reasons why invitations were declined by potential recruiters

-   Which recruiters continued past orientation and which did not

-   Reasons why specific recruiters did not continue past orientation

[When to enter data on the form]{.underline}

> This log should be used when identifying, screening, and contacting
> potential recruiters. It should be used to document which recruiters
> were enlisted and which recruiters did not enlist (and why). The log
> should also be used to record which recruiters continued past
> orientation (and reasons why certain recruiters did not continue).

[How to use the data in the log]{.underline}

> Data collected with the log can be used to compute performance
> measures related to recruiter participation (performance measures are
> described in the Monitoring and Evaluation Plan). The log is also
> useful for keeping a record of the general recruiter enlistment
> process.

## Field descriptions

> **Participant ID \#**

-   Unique ID \# assigned to each program participant

-   May be entered for each potential recruiter that is already involved
    in program as a network associate (and thus already has an ID #)

-   If person is a network associate already, ID \# can be retrieved
    from the associate's Participant Data Form

> **Name of potential recruiter**

-   Potential recruiter's name

> **Met criteria?**

-   Does individual meet the criteria for being a recruiter (i.e., meets
    requirements for participation as a recruiter)?

-   Circle Yes (*Y*) or No (*N*).

> **Date invited**

-   Date the individual was invited to be a recruiter

> **Enlisted?**

-   Is the individual enlisted as a recruiter (i.e., the person agrees
    to be a recruiter)?

-   Circle Yes (*Y*) or No (*N*).

> **Date enlisted**

-   Date the individual is enlisted as a recruiter (i.e., the date that
    he/she accepted the invitation)

> **Previously an associate?**

-   Was the individual previously a network associate in the program?
    Search your database or other documentation to determine if this
    person is already registered as a network associate in the program.

-   Circle Yes (*Y*) or No (*N*).

> **Reason for not enlisting**

-   If the individual does not want to enlist, what is the reason?

> **Cont'd past orientation?**

-   Did the recruiter continue with the program after recruiter
    orientation? Complete this item for each recruiter as soon as he/she
    successfully completes orientation or when he/she drops out of
    orientation for some reason.

-   Circle Yes (*Y*) or No (*N*).

> **If did not continue past orientation, why not?**

-   If the individual did not continue past orientation, what is the
    reason?

> **Comments**

-   Provider comments about this person (e.g., enlistment or orientation
    issues that arose, reasons why he/she did not meet recruiter
    criteria, issues arising during orientation that might have caused
    him/her to drop out, plans for following-up with person if he/she is
    not currently interested in recruiting but may be interested in the
    future)

## Example

<table>
<colgroup>
<col style="width: 8%" />
<col style="width: 15%" />
<col style="width: 6%" />
<col style="width: 7%" />
<col style="width: 6%" />
<col style="width: 7%" />
<col style="width: 6%" />
<col style="width: 14%" />
<col style="width: 6%" />
<col style="width: 18%" />
</colgroup>
<tbody>
<tr class="odd">
<td><p>Participant</p>
<p>ID #</p></td>
<td><p>Name of</p>
<p>potential recruiter</p></td>
<td>Met criteria?</td>
<td><p>Date</p>
<p>invited</p></td>
<td>Enlisted?</td>
<td><p>Date</p>
<p>enlisted</p></td>
<td><p>Prev. an</p>
<p>assoc.?</p></td>
<td><p>Reason for not</p>
<p>enlisting</p></td>
<td>Cont’d past orient.?</td>
<td>If did not continue past orientation, why not?</td>
</tr>
<tr class="even">
<td rowspan="3"></td>
<td><p>Last:</p>
<p>Brown</p></td>
<td rowspan="3">Y N</td>
<td rowspan="3"><blockquote>
<p>1/10/07</p>
</blockquote></td>
<td rowspan="3">Y N</td>
<td rowspan="3"><blockquote>
<p>1/10/07</p>
</blockquote></td>
<td rowspan="3">Y N</td>
<td rowspan="3"></td>
<td rowspan="3">Y N</td>
<td rowspan="3"></td>
</tr>
<tr class="odd">
<td><p>First:</p>
<p>John</p></td>
</tr>
<tr class="even">
<td>Nicknames/aliases:</td>
</tr>
<tr class="odd">
<td colspan="10"><em>Comments:</em> He has large network of IDUs
(Provider # 312)</td>
</tr>
<tr class="even">
<td rowspan="3"></td>
<td><p>Last:</p>
<p>Smith</p></td>
<td rowspan="3">Y N</td>
<td rowspan="3"></td>
<td rowspan="3">Y N</td>
<td rowspan="3"></td>
<td rowspan="3">Y N</td>
<td rowspan="3"></td>
<td rowspan="3">Y N</td>
<td rowspan="3"></td>
</tr>
<tr class="odd">
<td><p>First:</p>
<p>James</p></td>
</tr>
<tr class="even">
<td><p>Nicknames/aliases:</p>
<p>Jimmy, JJ</p></td>
</tr>
<tr class="odd">
<td colspan="10"><em>Comments:</em> Violent history, including past
aggressive behavior toward outreach workers and people at the local
homeless shelter. He should not be invited to enlist in this program-
lives in Homestead Apartments on 8<sup>th</sup> St. (Provider #21)</td>
</tr>
<tr class="even">
<td rowspan="3">1-15</td>
<td><p>Last:</p>
<p>Gordon</p></td>
<td rowspan="3">Y N</td>
<td rowspan="3"><blockquote>
<p>1/10/07</p>
</blockquote></td>
<td rowspan="3">Y N</td>
<td rowspan="3"><blockquote>
<p>1/10/07</p>
</blockquote></td>
<td rowspan="3">Y N</td>
<td rowspan="3"></td>
<td rowspan="3">Y N</td>
<td rowspan="3">Did not complete orientation sessions, said she is too
busy</td>
</tr>
<tr class="odd">
<td><p>First:</p>
<p>Ramona</p></td>
</tr>
<tr class="even">
<td>Nicknames/aliases:</td>
</tr>
<tr class="odd">
<td colspan="10"><em>Comments:</em> Used to be an associate. 1/30/07-
She did not show up for the last orientation session. Have been
unsuccessful in contacting her, I will keep trying to call her (Provider
#312); 3/1/07- Don’t think she will be a reliable recruiter, she keeps
missing scheduled orientation (Provider # 312)</td>
</tr>
<tr class="even">
<td rowspan="3">1-19</td>
<td><p>Last:</p>
<p>Rivera</p></td>
<td rowspan="3">Y N</td>
<td rowspan="3"><blockquote>
<p>3/10/07</p>
</blockquote></td>
<td rowspan="3">Y N</td>
<td rowspan="3"></td>
<td rowspan="3">Y N</td>
<td rowspan="3">Not comfortable talking about HIV with friends (afraid
they might learn her status)</td>
<td rowspan="3">Y N</td>
<td rowspan="3"></td>
</tr>
<tr class="odd">
<td><p>First:</p>
<p>Geraldine</p></td>
</tr>
<tr class="even">
<td>Nicknames/aliases:</td>
</tr>
<tr class="odd">
<td colspan="10"><em>Comments:</em> 3/10/07- She said it was okay to
follow-up with her in 3 months (06/10/07) to see if her feelings have
changed about being a recruiter. (Provider #315)</td>
</tr>
</tbody>
</table>

# SECTION THREE: PARTICIPANT REGISTRATION FORM

[Purpose]{.underline}

> The purpose of the Participant Registration Form is to register all
> participants in the social networks testing program (recruiters,
> network associates). This form is designed for use with all
> participants.

[Description]{.underline}

> This form is useful for helping program managers:

-   Document identifying information about each participant

-   Document locating and contact information for each participant

-   Link each participant to a unique participant identifier

[When to enter data on the form]{.underline}

-   For recruiters- Complete this form when the recruiter begins
    orientation, or alternatively, when the recruiter is enlisted in the
    program

-   For network associates- Complete this form as soon as possible after
    initial contact with the individual

[How to use the data in this form]{.underline}

> Registration data collected can be used to document identifying
> information about each person involved in the social networks testing
> program. Staff members may also look up locating and contact
> information when it is necessary to follow-up with participants.

## Field descriptions

> **Participant ID \#**

-   Unique ID \# assigned to each program participant

> **Date form completed**

-   Date the participant was registered in the program

> **Provider ID \# (Intake performed by)**

-   ID \# of the staff member who registers the participant.

> **Last name, first name, nicknames/aliases**

-   Participant's name

> **Gender**

-   Gender (*Male, Female, Transgender,* or *Unknown*)

> **Ethnicity**

-   Ethnicity (*Hispanic or Latino, Not Hispanic or Latino*, or
    *Unknown*).

> **Race**

-   Race (*American Indian/Alaskan Native, Asian, Black/African
    American, Native Hawaiian/Pacific Islander, White*, or *Other*)

-   If *Other*, specify other race

> **Date of birth**

-   Date of birth

-   Enter date of birth

> **Age (when participant was registered)**

-   Age of the participant when he/she is registered

> **Address 1, Address 2**

-   Street address, city, state, and zip code of the current residence
    of the participant. A second address may be entered, if desired.

> **Phone 1, Phone 2, Phone 3**

-   Up to three different phone numbers for the participant. For each
    phone number, indicate phone type (*Home, Work, Cell,* or *Other*).

-   If *Other*, specify other type of phone

> **Other contact persons**

-   Contact information for up to two people who may be able to help
    find the participant in the future (e.g., if he/she cannot be
    reached via phone) can be recorded here

## Example

Participant information:

+-----------+-----------+----+---+--------------+---+---+----------------+
| Pa        |           |    | D |              |   |   |                |
| rticipant |           |    | a |              |   |   |                |
| ID \# :   |           |    | t |              |   |   |                |
| 1-13      |           |    | e |              |   |   |                |
|           |           |    | f |              |   |   |                |
|           |           |    | o |              |   |   |                |
|           |           |    | r |              |   |   |                |
|           |           |    | m |              |   |   |                |
|           |           |    | c |              |   |   |                |
|           |           |    | o |              |   |   |                |
|           |           |    | m |              |   |   |                |
|           |           |    | p |              |   |   |                |
|           |           |    | l |              |   |   |                |
|           |           |    | e |              |   |   |                |
|           |           |    | t |              |   |   |                |
|           |           |    | e |              |   |   |                |
|           |           |    | d |              |   |   |                |
|           |           |    | : |              |   |   |                |
|           |           |    | 6 |              |   |   |                |
|           |           |    | / |              |   |   |                |
|           |           |    | 1 |              |   |   |                |
|           |           |    | 0 |              |   |   |                |
|           |           |    | / |              |   |   |                |
|           |           |    | 2 |              |   |   |                |
|           |           |    | 0 |              |   |   |                |
|           |           |    | 0 |              |   |   |                |
|           |           |    | 7 |              |   |   |                |
+-----------+-----------+----+---+--------------+---+---+----------------+
| Provider  |           |    |   |              |   |   |                |
| ID \#     |           |    |   |              |   |   |                |
| (Intake   |           |    |   |              |   |   |                |
| performed |           |    |   |              |   |   |                |
| by): 4101 |           |    |   |              |   |   |                |
+-----------+-----------+----+---+--------------+---+---+----------------+
| Last      |           |    | F |              |   |   | Nick           |
| name:     |           |    | i |              |   |   | names/aliases: |
|           |           |    | r |              |   |   |                |
| Tennebaum |           |    | s |              |   |   |                |
|           |           |    | t |              |   |   |                |
|           |           |    | n |              |   |   |                |
|           |           |    | a |              |   |   |                |
|           |           |    | m |              |   |   |                |
|           |           |    | e |              |   |   |                |
|           |           |    | : |              |   |   |                |
|           |           |    |   |              |   |   |                |
|           |           |    | H |              |   |   |                |
|           |           |    | a |              |   |   |                |
|           |           |    | r |              |   |   |                |
|           |           |    | o |              |   |   |                |
|           |           |    | l |              |   |   |                |
|           |           |    | d |              |   |   |                |
+-----------+-----------+----+---+--------------+---+---+----------------+
| Gender:   | E         |    | R |              |   |   | Date of birth: |
|           | thnicity: |    | a |              |   |   |                |
|           |           |    | c |              |   |   |                |
|           |           |    | e |              |   |   |                |
|           |           |    | : |              |   |   |                |
+-----------+-----------+----+---+--------------+---+---+----------------+
|  Male    |          |    | ⁪  |              |   |   | 11/22/1970     |
|           | Hispanic  |    | A |              |   |   |                |
|           | or Latino |    | m |              |   |   |                |
|           |           |    | e |              |   |   |                |
|           |           |    | r |              |   |   |                |
|           |           |    | i |              |   |   |                |
|           |           |    | c |              |   |   |                |
|           |           |    | a |              |   |   |                |
|           |           |    | n |              |   |   |                |
|           |           |    | I |              |   |   |                |
|           |           |    | n |              |   |   |                |
|           |           |    | d |              |   |   |                |
|           |           |    | i |              |   |   |                |
|           |           |    | a |              |   |   |                |
|           |           |    | n |              |   |   |                |
|           |           |    | / |              |   |   |                |
|           |           |    | A |              |   |   |                |
|           |           |    | l |              |   |   |                |
|           |           |    | a |              |   |   |                |
|           |           |    | s |              |   |   |                |
|           |           |    | k |              |   |   |                |
|           |           |    | a |              |   |   |                |
|           |           |    | n |              |   |   |                |
|           |           |    | N |              |   |   |                |
|           |           |    | a |              |   |   |                |
|           |           |    | t |              |   |   |                |
|           |           |    | i |              |   |   |                |
|           |           |    | v |              |   |   |                |
|           |           |    | e |              |   |   |                |
+-----------+-----------+----+---+--------------+---+---+----------------+
| ⁪Female    | ⁪Not       |    | ⁪  |              |   |   |                |
|           | Hispanic  |    | A |              |   |   |                |
|           | or        |    | s |              |   |   |                |
|           |           |    | i |              |   |   |                |
|           |           |    | a |              |   |   |                |
|           |           |    | n |              |   |   |                |
+-----------+-----------+----+---+--------------+---+---+----------------+
| ⁪          | Latino    |    | ⁪  |              |   |   | Age (when      |
| Tr        |           |    | B |              |   |   | participant    |
| ansgender |           |    | l |              |   |   | was            |
|           |           |    | a |              |   |   |                |
|           |           |    | c |              |   |   |                |
|           |           |    | k |              |   |   |                |
|           |           |    | / |              |   |   |                |
|           |           |    | A |              |   |   |                |
|           |           |    | f |              |   |   |                |
|           |           |    | r |              |   |   |                |
|           |           |    | i |              |   |   |                |
|           |           |    | c |              |   |   |                |
|           |           |    | a |              |   |   |                |
|           |           |    | n |              |   |   |                |
|           |           |    | A |              |   |   |                |
|           |           |    | m |              |   |   |                |
|           |           |    | e |              |   |   |                |
|           |           |    | r |              |   |   |                |
|           |           |    | i |              |   |   |                |
|           |           |    | c |              |   |   |                |
|           |           |    | a |              |   |   |                |
|           |           |    | n |              |   |   |                |
+-----------+-----------+----+---+--------------+---+---+----------------+
| ⁪Unknown   | ⁪Unknown   |    | ⁪  |              |   |   | registered):   |
|           |           |    | N |              |   |   | 36             |
|           |           |    | a |              |   |   |                |
|           |           |    | t |              |   |   |                |
|           |           |    | i |              |   |   |                |
|           |           |    | v |              |   |   |                |
|           |           |    | e |              |   |   |                |
|           |           |    | H |              |   |   |                |
|           |           |    | a |              |   |   |                |
|           |           |    | w |              |   |   |                |
|           |           |    | a |              |   |   |                |
|           |           |    | i |              |   |   |                |
|           |           |    | i |              |   |   |                |
|           |           |    | a |              |   |   |                |
|           |           |    | n |              |   |   |                |
|           |           |    | / |              |   |   |                |
|           |           |    | P |              |   |   |                |
|           |           |    | a |              |   |   |                |
|           |           |    | c |              |   |   |                |
|           |           |    | i |              |   |   |                |
|           |           |    | f |              |   |   |                |
|           |           |    | i |              |   |   |                |
|           |           |    | c |              |   |   |                |
|           |           |    | I |              |   |   |                |
|           |           |    | s |              |   |   |                |
|           |           |    | l |              |   |   |                |
|           |           |    | a |              |   |   |                |
|           |           |    | n |              |   |   |                |
|           |           |    | d |              |   |   |                |
|           |           |    | e |              |   |   |                |
|           |           |    | r |              |   |   |                |
+-----------+-----------+----+---+--------------+---+---+----------------+
|           |           |    |  |              |   |   |                |
|           |           |    | W |              |   |   |                |
|           |           |    | h |              |   |   |                |
|           |           |    | i |              |   |   |                |
|           |           |    | t |              |   |   |                |
|           |           |    | e |              |   |   |                |
+-----------+-----------+----+---+--------------+---+---+----------------+
|           |           |    | ⁪  |              |   |   |                |
|           |           |    | O |              |   |   |                |
|           |           |    | t |              |   |   |                |
|           |           |    | h |              |   |   |                |
|           |           |    | e |              |   |   |                |
|           |           |    | r |              |   |   |                |
|           |           |    | \ |              |   |   |                |
|           |           |    | _ |              |   |   |                |
|           |           |    | \ |              |   |   |                |
|           |           |    | _ |              |   |   |                |
|           |           |    | \ |              |   |   |                |
|           |           |    | _ |              |   |   |                |
|           |           |    | \ |              |   |   |                |
|           |           |    | _ |              |   |   |                |
|           |           |    | \ |              |   |   |                |
|           |           |    | _ |              |   |   |                |
|           |           |    | \ |              |   |   |                |
|           |           |    | _ |              |   |   |                |
|           |           |    | \ |              |   |   |                |
|           |           |    | _ |              |   |   |                |
|           |           |    | \ |              |   |   |                |
|           |           |    | _ |              |   |   |                |
|           |           |    | \ |              |   |   |                |
|           |           |    | _ |              |   |   |                |
|           |           |    | \ |              |   |   |                |
|           |           |    | _ |              |   |   |                |
|           |           |    | \ |              |   |   |                |
|           |           |    | _ |              |   |   |                |
|           |           |    | \ |              |   |   |                |
|           |           |    | _ |              |   |   |                |
|           |           |    | \ |              |   |   |                |
|           |           |    | _ |              |   |   |                |
|           |           |    | \ |              |   |   |                |
|           |           |    | _ |              |   |   |                |
|           |           |    | \ |              |   |   |                |
|           |           |    | _ |              |   |   |                |
|           |           |    | \ |              |   |   |                |
|           |           |    | _ |              |   |   |                |
|           |           |    | \ |              |   |   |                |
|           |           |    | _ |              |   |   |                |
|           |           |    | \ |              |   |   |                |
|           |           |    | _ |              |   |   |                |
|           |           |    | \ |              |   |   |                |
|           |           |    | _ |              |   |   |                |
|           |           |    | \ |              |   |   |                |
|           |           |    | _ |              |   |   |                |
|           |           |    | \ |              |   |   |                |
|           |           |    | _ |              |   |   |                |
|           |           |    | \ |              |   |   |                |
|           |           |    | _ |              |   |   |                |
|           |           |    | \ |              |   |   |                |
|           |           |    | _ |              |   |   |                |
+-----------+-----------+----+---+--------------+---+---+----------------+
|           |           |    |   |              |   |   |                |
+-----------+-----------+----+---+--------------+---+---+----------------+
| [Address  |           |    |   |              |   |   |                |
| 1]{.u     |           |    |   |              |   |   |                |
| nderline} |           |    |   |              |   |   |                |
+-----------+-----------+----+---+--------------+---+---+----------------+
| Street    |           |    |   |              |   |   |                |
| address:  |           |    |   |              |   |   |                |
|           |           |    |   |              |   |   |                |
| 123       |           |    |   |              |   |   |                |
| Broadway  |           |    |   |              |   |   |                |
| Ave.,     |           |    |   |              |   |   |                |
| Unit 11   |           |    |   |              |   |   |                |
+-----------+-----------+----+---+--------------+---+---+----------------+
| City:     |           |    |   | State:       | Z |   |                |
|           |           |    |   |              | i |   |                |
| Conway    |           |    |   | Georgia      | p |   |                |
|           |           |    |   |              | c |   |                |
|           |           |    |   |              | o |   |                |
|           |           |    |   |              | d |   |                |
|           |           |    |   |              | e |   |                |
|           |           |    |   |              | : |   |                |
|           |           |    |   |              |   |   |                |
|           |           |    |   |              | 1 |   |                |
|           |           |    |   |              | 2 |   |                |
|           |           |    |   |              | 3 |   |                |
|           |           |    |   |              | 4 |   |                |
|           |           |    |   |              | 5 |   |                |
+-----------+-----------+----+---+--------------+---+---+----------------+
| [Address  |           |    |   |              |   |   |                |
| 2]{.u     |           |    |   |              |   |   |                |
| nderline} |           |    |   |              |   |   |                |
+-----------+-----------+----+---+--------------+---+---+----------------+
| Street    |           |    |   |              |   |   |                |
| address:  |           |    |   |              |   |   |                |
|           |           |    |   |              |   |   |                |
| \_\_\_\_  |           |    |   |              |   |   |                |
| \_\_\_\_\ |           |    |   |              |   |   |                |
| _\_\_\_\_ |           |    |   |              |   |   |                |
| \_\_\_\_\ |           |    |   |              |   |   |                |
| _\_\_\_\_ |           |    |   |              |   |   |                |
| \_\_\_\_\ |           |    |   |              |   |   |                |
| _\_\_\_\_ |           |    |   |              |   |   |                |
| \_\_\_\_\ |           |    |   |              |   |   |                |
| _\_\_\_\_ |           |    |   |              |   |   |                |
| \_\_\_\_\ |           |    |   |              |   |   |                |
| _\_\_\_\_ |           |    |   |              |   |   |                |
| \_\_\_\_\ |           |    |   |              |   |   |                |
| _\_\_\_\_ |           |    |   |              |   |   |                |
| \_\_\_\_\ |           |    |   |              |   |   |                |
| _\_\_\_\_ |           |    |   |              |   |   |                |
| \_\_\_\_\ |           |    |   |              |   |   |                |
| _\_\_\_\_ |           |    |   |              |   |   |                |
| \_\_\_\_\ |           |    |   |              |   |   |                |
| _\_\_\_\_ |           |    |   |              |   |   |                |
| \_\_\_\_\ |           |    |   |              |   |   |                |
| _\_\_\_\_ |           |    |   |              |   |   |                |
+-----------+-----------+----+---+--------------+---+---+----------------+
| City:     |           |    |   | State:       | Z |   |                |
|           |           |    |   |              | i |   |                |
| \_\       |           |    |   | \_\_\_       | p |   |                |
| _\_\_\_\_ |           |    |   | \_\_\_\_\_\_ | c |   |                |
| \_\_\_\_\ |           |    |   |              | o |   |                |
| _\_\_\_\_ |           |    |   |              | d |   |                |
| \_\_\_\_\ |           |    |   |              | e |   |                |
| _\_\_\_\_ |           |    |   |              | : |   |                |
| \_\_\_\_\ |           |    |   |              |   |   |                |
| _\_\_\_\_ |           |    |   |              | \ |   |                |
|           |           |    |   |              | _ |   |                |
|           |           |    |   |              | \ |   |                |
|           |           |    |   |              | _ |   |                |
|           |           |    |   |              | \ |   |                |
|           |           |    |   |              | _ |   |                |
|           |           |    |   |              | \ |   |                |
|           |           |    |   |              | _ |   |                |
|           |           |    |   |              | \ |   |                |
|           |           |    |   |              | _ |   |                |
|           |           |    |   |              | \ |   |                |
|           |           |    |   |              | _ |   |                |
|           |           |    |   |              | \ |   |                |
|           |           |    |   |              | _ |   |                |
|           |           |    |   |              | \ |   |                |
|           |           |    |   |              | _ |   |                |
|           |           |    |   |              | \ |   |                |
|           |           |    |   |              | _ |   |                |
|           |           |    |   |              | \ |   |                |
|           |           |    |   |              | _ |   |                |
|           |           |    |   |              | \ |   |                |
|           |           |    |   |              | _ |   |                |
|           |           |    |   |              | \ |   |                |
|           |           |    |   |              | _ |   |                |
|           |           |    |   |              | \ |   |                |
|           |           |    |   |              | _ |   |                |
|           |           |    |   |              | \ |   |                |
|           |           |    |   |              | _ |   |                |
|           |           |    |   |              | \ |   |                |
|           |           |    |   |              | _ |   |                |
|           |           |    |   |              | \ |   |                |
|           |           |    |   |              | _ |   |                |
|           |           |    |   |              | \ |   |                |
|           |           |    |   |              | _ |   |                |
|           |           |    |   |              | \ |   |                |
|           |           |    |   |              | _ |   |                |
|           |           |    |   |              | \ |   |                |
|           |           |    |   |              | _ |   |                |
|           |           |    |   |              | \ |   |                |
|           |           |    |   |              | _ |   |                |
|           |           |    |   |              | \ |   |                |
|           |           |    |   |              | _ |   |                |
|           |           |    |   |              | \ |   |                |
|           |           |    |   |              | _ |   |                |
+-----------+-----------+----+---+--------------+---+---+----------------+
|           |           | [P |   |              |   |   |                |
|           |           | ho |   |              |   |   |                |
|           |           | ne |   |              |   |   |                |
|           |           | Nu |   |              |   |   |                |
|           |           | mb |   |              |   |   |                |
|           |           | er |   |              |   |   |                |
|           |           | s] |   |              |   |   |                |
|           |           | {. |   |              |   |   |                |
|           |           | un |   |              |   |   |                |
|           |           | de |   |              |   |   |                |
|           |           | rl |   |              |   |   |                |
|           |           | in |   |              |   |   |                |
|           |           | e} |   |              |   |   |                |
+-----------+-----------+----+---+--------------+---+---+----------------+
| Phone 1:  |           | P  |   |              |   | P |                |
| (555)     |           | ho |   |              |   | h |                |
| 121 -     |           | ne |   |              |   | o |                |
| 2323      |           | 2: |   |              |   | n |                |
|           |           | (  |   |              |   | e |                |
|           |           | 55 |   |              |   | 3 |                |
|           |           | 5) |   |              |   | : |                |
|           |           | 5  |   |              |   | ( |                |
|           |           | 32 |   |              |   | ) |                |
|           |           |  - |   |              |   | - |                |
|           |           | 88 |   |              |   |   |                |
|           |           | 76 |   |              |   |   |                |
+-----------+-----------+----+---+--------------+---+---+----------------+
| *Home     |           | *  |   |              |   | * |                |
| Work Cell |           | Ho |   |              |   | H |                |
| Other*    |           | me |   |              |   | o |                |
| N         |           | Wo |   |              |   | m |                |
| eighbor's |           | rk |   |              |   | e |                |
|           |           | Ce |   |              |   | W |                |
|           |           | ll |   |              |   | o |                |
|           |           | O  |   |              |   | r |                |
|           |           | th |   |              |   | k |                |
|           |           | er |   |              |   | C |                |
|           |           | \  |   |              |   | e |                |
|           |           | _\ |   |              |   | l |                |
|           |           | _\ |   |              |   | l |                |
|           |           | _\ |   |              |   | O |                |
|           |           | _\ |   |              |   | t |                |
|           |           | _* |   |              |   | h |                |
|           |           |    |   |              |   | e |                |
|           |           |    |   |              |   | r |                |
|           |           |    |   |              |   | \ |                |
|           |           |    |   |              |   | _ |                |
|           |           |    |   |              |   | \ |                |
|           |           |    |   |              |   | _ |                |
|           |           |    |   |              |   | \ |                |
|           |           |    |   |              |   | _ |                |
|           |           |    |   |              |   | \ |                |
|           |           |    |   |              |   | _ |                |
|           |           |    |   |              |   | \ |                |
|           |           |    |   |              |   | _ |                |
|           |           |    |   |              |   | * |                |
+-----------+-----------+----+---+--------------+---+---+----------------+

**Other contact persons**:

+----------------------------+----+---+-------------+--------------------+
| Name:                      |    | R |             |                    |
|                            |    | e |             |                    |
| Martha Rosslyn             |    | l |             |                    |
|                            |    | a |             |                    |
|                            |    | t |             |                    |
|                            |    | i |             |                    |
|                            |    | o |             |                    |
|                            |    | n |             |                    |
|                            |    | s |             |                    |
|                            |    | h |             |                    |
|                            |    | i |             |                    |
|                            |    | p |             |                    |
|                            |    | t |             |                    |
|                            |    | o |             |                    |
|                            |    | p |             |                    |
|                            |    | a |             |                    |
|                            |    | r |             |                    |
|                            |    | t |             |                    |
|                            |    | i |             |                    |
|                            |    | c |             |                    |
|                            |    | i |             |                    |
|                            |    | p |             |                    |
|                            |    | a |             |                    |
|                            |    | n |             |                    |
|                            |    | t |             |                    |
|                            |    | : |             |                    |
|                            |    |   |             |                    |
|                            |    | M |             |                    |
|                            |    | o |             |                    |
|                            |    | t |             |                    |
|                            |    | h |             |                    |
|                            |    | e |             |                    |
|                            |    | r |             |                    |
+----------------------------+----+---+-------------+--------------------+
| Street address:            |    |   |             |                    |
|                            |    |   |             |                    |
| 1205 Rosewood Way          |    |   |             |                    |
+----------------------------+----+---+-------------+--------------------+
| City:                      | St |   | Zip code:   | Phone:             |
|                            | at |   |             |                    |
| Peachtree City             | e: |   | 23323       | \(555\) 222 - 3232 |
|                            |    |   |             |                    |
|                            | GA |   |             |                    |
+----------------------------+----+---+-------------+--------------------+
|                            |    |   |             |                    |
+----------------------------+----+---+-------------+--------------------+
| Name:                      |    | R |             |                    |
|                            |    | e |             |                    |
| \_\_\_\_                   |    | l |             |                    |
| \_\_\_\_\_\_\_\_\_\_\_\_\_ |    | a |             |                    |
| \_\_\_\_\_\_\_\_\_\_\_\_\_ |    | t |             |                    |
| \_\_\_\_\_\_\_\_\_\_\_\_\_ |    | i |             |                    |
|                            |    | o |             |                    |
|                            |    | n |             |                    |
|                            |    | s |             |                    |
|                            |    | h |             |                    |
|                            |    | i |             |                    |
|                            |    | p |             |                    |
|                            |    | t |             |                    |
|                            |    | o |             |                    |
|                            |    | p |             |                    |
|                            |    | a |             |                    |
|                            |    | r |             |                    |
|                            |    | t |             |                    |
|                            |    | i |             |                    |
|                            |    | c |             |                    |
|                            |    | i |             |                    |
|                            |    | p |             |                    |
|                            |    | a |             |                    |
|                            |    | n |             |                    |
|                            |    | t |             |                    |
|                            |    | : |             |                    |
|                            |    |   |             |                    |
|                            |    | \ |             |                    |
|                            |    | _ |             |                    |
|                            |    | \ |             |                    |
|                            |    | _ |             |                    |
|                            |    | \ |             |                    |
|                            |    | _ |             |                    |
|                            |    | \ |             |                    |
|                            |    | _ |             |                    |
|                            |    | \ |             |                    |
|                            |    | _ |             |                    |
|                            |    | \ |             |                    |
|                            |    | _ |             |                    |
|                            |    | \ |             |                    |
|                            |    | _ |             |                    |
|                            |    | \ |             |                    |
|                            |    | _ |             |                    |
|                            |    | \ |             |                    |
|                            |    | _ |             |                    |
|                            |    | \ |             |                    |
|                            |    | _ |             |                    |
|                            |    | \ |             |                    |
|                            |    | _ |             |                    |
|                            |    | \ |             |                    |
|                            |    | _ |             |                    |
|                            |    | \ |             |                    |
|                            |    | _ |             |                    |
|                            |    | \ |             |                    |
|                            |    | _ |             |                    |
|                            |    | \ |             |                    |
|                            |    | _ |             |                    |
|                            |    | \ |             |                    |
|                            |    | _ |             |                    |
|                            |    | \ |             |                    |
|                            |    | _ |             |                    |
|                            |    | \ |             |                    |
|                            |    | _ |             |                    |
|                            |    | \ |             |                    |
|                            |    | _ |             |                    |
|                            |    | \ |             |                    |
|                            |    | _ |             |                    |
|                            |    | \ |             |                    |
|                            |    | _ |             |                    |
|                            |    | \ |             |                    |
|                            |    | _ |             |                    |
|                            |    | \ |             |                    |
|                            |    | _ |             |                    |
|                            |    | \ |             |                    |
|                            |    | _ |             |                    |
|                            |    | \ |             |                    |
|                            |    | _ |             |                    |
|                            |    | \ |             |                    |
|                            |    | _ |             |                    |
|                            |    | \ |             |                    |
|                            |    | _ |             |                    |
|                            |    | \ |             |                    |
|                            |    | _ |             |                    |
|                            |    | \ |             |                    |
|                            |    | _ |             |                    |
|                            |    | \ |             |                    |
|                            |    | _ |             |                    |
|                            |    | \ |             |                    |
|                            |    | _ |             |                    |
|                            |    | \ |             |                    |
|                            |    | _ |             |                    |
|                            |    | \ |             |                    |
|                            |    | _ |             |                    |
|                            |    | \ |             |                    |
|                            |    | _ |             |                    |
|                            |    | \ |             |                    |
|                            |    | _ |             |                    |
|                            |    | \ |             |                    |
|                            |    | _ |             |                    |
|                            |    | \ |             |                    |
|                            |    | _ |             |                    |
|                            |    | \ |             |                    |
|                            |    | _ |             |                    |
|                            |    | \ |             |                    |
|                            |    | _ |             |                    |
|                            |    | \ |             |                    |
|                            |    | _ |             |                    |
|                            |    | \ |             |                    |
|                            |    | _ |             |                    |
|                            |    | \ |             |                    |
|                            |    | _ |             |                    |
|                            |    | \ |             |                    |
|                            |    | _ |             |                    |
|                            |    | \ |             |                    |
|                            |    | _ |             |                    |
|                            |    | \ |             |                    |
|                            |    | _ |             |                    |
|                            |    | \ |             |                    |
|                            |    | _ |             |                    |
+----------------------------+----+---+-------------+--------------------+
| Street address:            |    |   |             |                    |
|                            |    |   |             |                    |
| \_\_                       |    |   |             |                    |
| \_\_\_\_\_\_\_\_\_\_\_\_\_ |    |   |             |                    |
| \_\_\_\_\_\_\_\_\_\_\_\_\_ |    |   |             |                    |
| \_\_\_\_\_\_\_\_\_\_\_\_\_ |    |   |             |                    |
| \_\_\_\_\_\_\_\_\_\_\_\_\_ |    |   |             |                    |
| \_\_\_\_\_\_\_\_\_\_\_\_\_ |    |   |             |                    |
| \_\_\_\_\_\_\_\_\_\_\_\_\_ |    |   |             |                    |
| \_\_\_\_\_\_\_\_\_\_\_\_\_ |    |   |             |                    |
+----------------------------+----+---+-------------+--------------------+
| City:                      | St |   | Zip code:   | Phone:             |
|                            | at |   |             |                    |
| \_\_\_\_\_\_\_\_\_\_\_     | e: |   | \           | ( ) -              |
| \_\_\_\_\_\_\_\_\_\_\_\_\_ |    |   | _\_\_\_\_\_ |                    |
| \_\_\_\_\_\_\_\_\_\_\_\_\_ | \_ |   | \_\_\_\_\_\ |                    |
|                            | \_ |   | _\_\_\_\_\_ |                    |
|                            | \_ |   |             |                    |
|                            | \_ |   |             |                    |
|                            | \_ |   |             |                    |
|                            | \_ |   |             |                    |
|                            | \_ |   |             |                    |
+----------------------------+----+---+-------------+--------------------+

# SECTION FOUR: PARTICIPANT DATA FORM

[Purpose]{.underline}

> The purpose of the Participant Data Form is to collect all
> non-identifying data on social networks testing participants. This
> form is designed for use with all participants.

[Description]{.underline}

> This form will be used to collect demographic, HIV testing history,
> and risk data for every participant. For recruiters, the form will
> also be used to document all interviews and general recruiter issues.
> For network associates who get tested, the form will also be used to
> collect CTR data. CTR data for active recruiters in the program should
> also be documented here (e.g., if a recruiter wants to get tested
> while involved in the social networks testing program).

[When to enter data in the form]{.underline}

> See "Field descriptions" for each individual section.

[How to use the data in this form]{.underline}

> Participant data collected can be used to address performance measures
> related to orientation/interviewing/coaching of recruiters,
> recruitment of network associates, and CTR activities (performance
> measures are described in the Monitoring and Evaluation Plan). Data
> can also be used for program evaluation comparisons and analyses.

## General Information Page (All Participants)

[When to enter data on this page]{.underline}

-   This page should be completed for all participants

-   For recruiters- Complete this page when the recruiter begins
    orientation, or alternatively, when the recruiter is enlisted in the
    program.

-   For network associates- Complete this page as soon as possible after
    initial contact with the individual

### *Field descriptions*

> **Participant ID \#**

-   Unique ID \# assigned to each program participant

> **Date**

-   Date this page was completed

> **Provider ID \# (Intake performed by)**

-   ID \# of the staff member who performed intake for the participant

> **Participant type**

-   Type of participant (*Recruiter, Direct Network Associate, Indirect
    Network Associate*) (described below)

    -   *Recruiter*- Person who will be providing names of network
        associates who are at risk for HIV and recruiting network
        associates for CTR

> *1^st^ Enlisted date*- This date should be the original date that the
> recruiter was enlisted into the program. Copy this information
> directly from the Recruiter Enlistment/Orientation Log.
>
> *1^st^ End date*- Date when recruiter stops being involved in program
> (whether temporary or permanent). Entering an end date allows program
> managers to determine exactly how long a recruiter was involved in the
> program.
>
> Up to 3 periods of service may be recorded for a recruiter. (A
> recruiter may decide to "end" service and "re-enlist" later for
> various reasons.)

-   *Direct network associate*- Person who has been directly identified
    by a recruiter

> Date of first encounter is the date the associate was first contacted
> about HIV testing by a recruiter

-   *Indirect network associate*- Person who has been identified by a
    network associate (and thus is considered to be indirectly linked to
    the recruiter)

> Date of first encounter is the date the associate first discussed
> getting tested with a direct network associate

-   If a recruiter, indicate if he/she continued (*Yes*) or did not
    continue (*No*) with the program after orientation. Enter
    appropriate enlistment/end dates.

-   If a network associate, enter date of 1^st^ encounter

> **DO NOT...**

-   ...select *Direct Network Associate* or *Indirect Network Associate*
    AFTER a person has already been enlisted in the program as a
    recruiter. Recruiters cannot "become" network associates after they
    are already actively recruiting for the program.

-   ...select a different type of network associate after a participant
    has already entered the program as the other type of network
    associate. For example, consider a person who is an indirect network
    associate referred to the program by a direct network associate. It
    is okay if a recruiter later identifies this person as one of his
    direct network associates, but the person's participant type should
    not change because he was initially "reached" through the social
    networks strategy by talking with a direct network associate.

> **Gender**

-   Gender (*Male, Female, Transgender*, or *Unknown*)

> **Ethnicity**

-   Ethnicity (*Hispanic or Latino, Not Hispanic or Latino,* or
    *Unknown*).

> **Race**

-   Race (*American Indian/Alaskan Native, Asian, Black/African
    American, Native Hawaiian/Pacific Islander, White,* or *Other*)

-   If *Other*, specify other race

> **Date of birth**

-   Date of birth

> **Age (when section was completed)**

-   Age of the participant when the General Information Page was
    completed

> **Zip code**

-   Optional

-   Zip code of participant's primary address; this information is
    optional but could be useful for programs interested in examining
    geographic differences

> **Risk group**

-   Primary risk group for this participant (*MSM, IDU, MSM/IDU,
    High-risk heterosexual, Unknown,* and/or *Other risk group*)

-   If *Other risk group*, specify other risk group

> **Marital status**

-   Participant's marital status (*Single, Partnered, Married,
    Separated, Divorced, Declined, Other status,* or *Unknown*)

-   If *Other status*, specify other risk group.

### *Example*

## 

  ---------------------------------- ------------------------------------
  Participant ID #: 1-13             Date: 6/10/2007

  Provider ID \# (Intake performed   
  by): 4101                          
  ---------------------------------- ------------------------------------

> **Section I. General Information (All Participants)**

+-------------------------------------+--------------------------------+
| 1.  Participant type:               |                                |
+-------------------------------------+--------------------------------+
| >  Recruiter                       |  Direct network associate     |
+-------------------------------------+--------------------------------+
| > Continued past orientation?  Yes | > Date of 1^st^ encounter:     |
|                                     | > 4/13/2007                    |
+-------------------------------------+--------------------------------+
| > ⁪ No                               |                                |
+-------------------------------------+--------------------------------+
| 1^st^ Enlisted date: 8/1/2004 1^st^ | ⁪Indirect network associate     |
| End date: \_ \_/\_ \_/\_ \_ \_ \_   |                                |
+-------------------------------------+--------------------------------+
|                                     | > Date of 1^st^ encounter:     |
|                                     | > \_\_ \_\_/\_\_ \_\_/\_\_     |
|                                     | > \_\_ \_\_ \_\_               |
+-------------------------------------+--------------------------------+
| 2^nd^ Enlisted date: \_ \_/\_ \_/\_ |                                |
| \_ \_ \_ 2^nd^ End date: \_ \_/\_   |                                |
| \_/\_ \_ \_ \_                      |                                |
+-------------------------------------+--------------------------------+
|                                     |                                |
+-------------------------------------+--------------------------------+
| 3^rd^ Enlisted date: \_ \_/\_ \_/\_ |                                |
| \_ \_ \_ 3^rd^ End date: \_ \_/\_   |                                |
| \_/\_ \_ \_ \_                      |                                |
+-------------------------------------+--------------------------------+
|                                     |                                |
+-------------------------------------+--------------------------------+

+-------------+---------------+--------------------+------------------+
| 2.  De      |               |                    |                  |
| mographics: |               |                    |                  |
+-------------+---------------+--------------------+------------------+
| Gender:     | Ethnicity:    | Race:              | Date of birth:   |
+-------------+---------------+--------------------+------------------+
|  Male      |  Hispanic or | ⁪American           | 11/22/1970       |
|             | Latino        | Indian/Alaskan     |                  |
+-------------+---------------+--------------------+------------------+
| ⁪Female      | ⁪Not Hispanic  | Native             |                  |
|             | or            |                    |                  |
+-------------+---------------+--------------------+------------------+
| ⁪            | Latino        | ⁪Asian              |                  |
| Transgender |               |                    |                  |
+-------------+---------------+--------------------+------------------+
| ⁪Unknown     | ⁪Unknown       | ⁪Black/African      | Age (when        |
|             |               | American           | section was      |
+-------------+---------------+--------------------+------------------+
|             |               | ⁪Native             | completed): 36   |
|             |               | Hawaiian/Pacific   |                  |
+-------------+---------------+--------------------+------------------+
|             |               | Islander           |                  |
+-------------+---------------+--------------------+------------------+
|             |               |  White            | Zip code: 12345  |
+-------------+---------------+--------------------+------------------+
|             |               | ⁪Other:             |                  |
|             |               | \_\_\_\_\_\_\_\_\_ |                  |
|             |               | \_\_\_\_\_\_\_\_\_ |                  |
+-------------+---------------+--------------------+------------------+

3.  Risk group:  MSM

> ⁪ IDU
>
> ⁪ MSM/IDU
>
> ⁪ High-risk heterosexual (Heterosexual who engages in at least one risk
> behavior
>
> listed in Risks section)
>
> ⁪ Unknown
>
> ⁪ Other risk
> group:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

4.  Marital status:

> ⁪ Single ⁪ Married ⁪ Divorced ⁪ Other status:\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
>  Partnered ⁪ Separated ⁪ Declined ⁪ Unknown

## Testing History Page (All Participants)

[When to enter data on this page]{.underline}

-   This page should be completed for all participants

-   Testing history for people PRIOR to joining in the social networks
    program should be entered on the top half of the page

-   If a person gets tested somewhere else AFTER they are in the social
    networks program, enter that information on the bottom half of the
    page (e.g., if a recruiter gets tested at a different agency while
    he is actively recruiting for your social networks program)

-   For recruiters- Complete this page when the recruiter begins
    orientation, or alternatively, when the recruiter is enlisted in the
    program.

-   For network associates- Complete this page as soon as possible after
    initial contact with the individual

### *Field descriptions*

> **Participant ID \#**

-   Unique ID \# assigned to each program participant

**[At entry into Social Networks Testing program:]{.underline}**

> **Provider ID \#**

-   ID \# of staff member who completed this section

> **Date**

-   Date this section was completed

> **Has participant previously been tested?**

-   Has person been given an HIV test in the past, before entering the
    social networks program?

-   Select Yes (*Y*), No (*N*), or Unknown (*Unknown*).

> **If Yes, approximate date of most recent test (if known)**

-   Most recent test date before entry into program

-   If only a partial date is known (e.g., month and year), enter the
    partial date

-   Select *Unknown* if test date is not known

> **Result of most recent test**

-   Most recent test result (before entry into Social Networks Testing
    program) (*Preliminary positive or Positive, Negative, Invalid or
    Indeterminate*, or *Unknown*)

**[If tested elsewhere after entry into Social Networks Testing
program:]{.underline}**

> **Provider ID \#**

-   ID \# of staff member who completed this section

> **Date**

-   Date this section was completed

> **Approximate date of test**

-   If applicable- approximate date of test outside of social networks
    program but while actively participating in social networks program
    (e.g., a recruiter gets tested at a different agency while being a
    recruiter for the social networks program)

-   If only a partial date is known (e.g., month and year), enter the
    partial date

-   Select [Unknown]{.underline} if test date is not known

> **Test result**

-   Test result of test taken outside of social networks program, after
    entering the SNDP program (*Preliminary positive or Positive,
    Negative, Invalid or Indeterminate, Unknown*)

### *Example*

  ----------------------------------- -----------------------------------
  Participant ID \# : 1-13            

  ----------------------------------- -----------------------------------

**Section II. Testing History (All Participants)**

> **At entry into Social Networks Testing program:**

  ---------------------------------- ------------------------------------
  Provider ID #: 4101                Date: 6/10/2007

  ---------------------------------- ------------------------------------

1.  Has participant previously been tested?  Yes

> ⁪ No
>
> ⁪ Unknown

2.  If Yes, approximate date of most recent test (if known):

> 7/ ? /2003 ⁪ Unknown

3.  Result of most recent test:

[Rapid]{.underline} [Standard or Confirmatory]{.underline}

⁪Preliminary positive ⁪ Positive

⁪Negative  Negative

⁪Invalid ⁪ Indeterminate

⁪Unknown ⁪ Unknown

> *(Note: Preliminary positives/positives should be verified.)*
>
> **[If tested elsewhere after entry]{.underline} into Social Networks
> Testing program:**

  -------------------------------------- -----------------------------------
  Provider ID #:                         Date: \_\_ \_\_/\_\_ \_\_/\_\_ \_\_
  \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_   \_\_ \_\_

  -------------------------------------- -----------------------------------

1.  Approximate date of test:

> \_\_ \_\_/\_\_ \_\_/\_\_ \_\_ \_\_ \_\_ ⁪ Unknown

2.  Test result:

[Rapid]{.underline} [Standard or Confirmatory]{.underline}

⁪Preliminary positive ⁪ Positive

⁪Negative ⁪ Negative

⁪Invalid ⁪ Indeterminate

⁪Unknown ⁪ Unknown

> *(Note: Preliminary positives/positives should be verified.)*

## Interview Page (Recruiters Only)

[When to enter data on this page]{.underline}

-   This page should be completed [for recruiters only]{.underline}

-   Information about individual network associates in a recruiter's
    network should be added to this page every time a recruiter is
    interviewed. Some of the information will be gathered during an
    actual interview but some information may be collected later (e.g.,
    after a recruiter reports that he/she has contacted a particular
    network associate).

### *Interview Page (Network Associates)*

#### *Field descriptions*

> **Participant ID \# (Recruiter)**

-   Unique ID \# assigned to each program participant

***\*\*\*\*\*\*\*\*\*\*\*\*Record the information below during the
recruiter interview\*\*\*\*\*\*\*\*\*\*\*\****

> **Interview record \#**

-   Unique \# assigned to each network associate entry (for a particular
    recruiter)

-   ID# consists of the recruiter's ID \# plus a unique identifier
    starting with 1. The record #'s should be incremented by 1 with
    every new network associate entry added to a particular recruiter's
    record. For example, interview record \# 2-34-23 would refer to the
    23rd network associate elicited from recruiter \# 2-34.

> **Provider ID \# (Interviewer)**

-   ID \# of the staff member who interviewed the recruiter

> **Date elicited**

-   Date the network associate was elicited from (identified by) the
    recruiter

> **Name type**

-   Type of name given for the network associate: full name (F), partial
    name (P), or anonymous (A)

> **Name**

-   Network associate's name. Enter as much as you can.

> **Description**

-   Descriptive information (*Age, Sex, Race, Height, Weight, Hair*)
    about the network associate

> ***\*\*\*\*\*\*\*\*\*\*\*\*Complete the items below during follow-up
> with recruiter)\*\*\*\*\*\*\*\*\*\*\*\****
>
> **Previously recruited?**

-   Has network associate been previously recruited? Search your
    database or client records as soon as possible after interviewing
    the recruiter to determine if the associate has been previously
    recruited (or designated for recruitment) by a different recruiter

-   Circle Yes (*Y*) or No (*N*)

-   If this person is enlisted in the program as a recruiter only, leave
    this field blank and explain in the **Comments** field that this
    person is a recruiter.

> **Date contacted**

-   Date on which the network associate was initially contacted by the
    recruiter

-   If the exact date of contact is unknown, get a close estimate

-   Leave blank if this person is a recruiter, or if the person is an
    associate who has been previously recruited or designated for
    recruitment by a different recruiter

> **Recruiter/associate records linked?**

-   Have the records of the recruiter and this network associate been
    linked in the database or in client records?

-   These two people are considered linked if:

1.  The network associate's Participant ID \# is recorded on this page
    in the Participant ID \# (Associate) field

> AND

2.  The recruiter's Participant ID \# is recorded on the Recruitment
    Method page in the network associate's Participant Data Form

-   Select Yes (*Y*) or No (*N*).

> **IMPORTANT!**
>
> If the network associate has been enlisted as a recruiter, this should
> have no effect on this person's interview record in his recruiter's
> Interview page. The person is still considered to be a network
> associate of the first recruiter even after he becomes a recruiter
> himself.
>
> **Status**

-   Status of this network associate entry (open or closed)

-   Select Open (*O*) or Closed (*C*)

> **IMPORTANT!**

-   An interview record should be closed if the associate is already
    registered in the program (whether as an associate only or also as a
    recruiter)

-   A record could also be closed after the associate has reported for
    CTR, or after some level of effort has been spent unsuccessfully
    trying to get the associate to get tested.

> **Date closed**

-   Date on which this network associate's entry is closed, if it is
    closed

> **Participant ID \# (Associate)**

-   Participant ID \# of the network associate

-   Search the database or client records after interviewing the
    recruiter to determine if this associate is already registered as a
    program participant (keep in mind it is possible this person could
    be a recruiter)

-   If he/she is already a participant, record his/her ID \# here

-   If the network associate is not in the system, but enters the
    program later, record his/her ID \# here as soon as possible.

> **Locating information**

-   Locating information regarding how to find the network associate

> **Comments**

-   Explanatory comments or other important information about the
    network associate (e.g., why an entry was closed, if an associate is
    already being recruited by another recruiter)

#### *Example*

  ------------------------------------- ---------------------------------
  Participant ID \# (Recruiter): 1-13   

  ------------------------------------- ---------------------------------

**Section III. Interview (Recruiters Only)**

**A. Network Associates**

<table>
<colgroup>
<col style="width: 6%" />
<col style="width: 9%" />
<col style="width: 6%" />
<col style="width: 6%" />
<col style="width: 12%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 5%" />
<col style="width: 7%" />
<col style="width: 6%" />
<col style="width: 6%" />
<col style="width: 6%" />
<col style="width: 6%" />
<col style="width: 9%" />
</colgroup>
<tbody>
<tr class="odd">
<td>Interview record #</td>
<td><p>Provider</p>
<p>ID #</p>
<p>(Interviewer)</p></td>
<td>Date elicited</td>
<td>Name type*</td>
<td>Name</td>
<td colspan="3">Description</td>
<td>Previously recruited?</td>
<td><p>Date</p>
<p>contacted</p></td>
<td>Recruiter/ associate records linked?</td>
<td>Status+</td>
<td>Date closed</td>
<td><p>Participant</p>
<p>ID # (Associate)</p></td>
</tr>
<tr class="even">
<td rowspan="4"><strong>1-13-1</strong></td>
<td rowspan="4">501</td>
<td rowspan="4">8/5/2007</td>
<td rowspan="4">F P A</td>
<td><p>Last:</p>
<p>J</p></td>
<td rowspan="2"><p>Age</p>
<p>30s</p></td>
<td rowspan="2"><p>Sex</p>
<p>M</p></td>
<td rowspan="2"><blockquote>
<p>Race</p>
</blockquote>
<p>Blk</p></td>
<td rowspan="4">Y N</td>
<td rowspan="4">8/12/2007</td>
<td rowspan="4">Y N</td>
<td rowspan="4">O C</td>
<td rowspan="4">8/20/2007</td>
<td rowspan="4">1-26</td>
</tr>
<tr class="odd">
<td rowspan="2"><p>First:</p>
<p>Harry</p></td>
</tr>
<tr class="even">
<td rowspan="2"><p>Ht.</p>
<p>6.4</p></td>
<td rowspan="2"><p>Wt.</p>
<p>200</p></td>
<td rowspan="2">Hair Blk</td>
</tr>
<tr class="odd">
<td>Nicknames/aliases:</td>
</tr>
<tr class="even">
<td colspan="14"><p>Locating information:</p>
<p>Lives in Bankhead Subdivision- hangs out at The Vibe (123 Main St.)
on weekends.</p></td>
</tr>
<tr class="odd">
<td colspan="14"><p><em>Comments:</em></p>
<p>Has tattoo on right arm of eagle- very tall</p></td>
</tr>
</tbody>
</table>

In this example, a recruiter (ID# 1-13) gave the name of this network
associate (Harry J.) to a provider (ID# 501) on Aug. 5, 2007. This was
the first network associate that the recruiter had named at that point
so the interview record \# is 1-13-1 (Note: this ID \# is the
recruiter's ID \# plus "1" to indicate this is the first associate
named).

The recruiter contacted the network associate soon after the interview.
The network associate went to the agency to get tested and was assigned
Participant ID \# 1-26. The network associate was asked by a staff
member what caused him to want to get tested for HIV and he indicated
that a friend had convinced him (the friend was the recruiter #1-13).
The staff member was able to look up the ID \# of this recruiter and
then record this network associate's ID# (1-26) on the recruiter's
Interview page. This is how the two individuals become linked.

***Interview Page (Recruiters Only)***

[When to enter data on this page]{.underline}

-   This page should be completed [for recruiters only]{.underline}

-   Issues reported by the recruiter may be recorded at any time (e.g.,
    during or after an interview, after a follow-up visit or phone call
    with a recruiter).

### *Interview Page (General Recruiter Issues)*

#### *Field descriptions*

> **Participant ID \#**

-   Unique ID \# assigned to each program participant

> **Date**

-   Date on which the issue was reported [by]{.underline} a recruiter

> **Provider ID \#**

-   ID \# of the staff member who reported the recruiter issue

> **Issues reported [by recruiter]{.underline}**

-   Issue(s) reported by the recruiter (general issues experienced by
    the recruiter related to recruitment efforts, barriers that he/she
    experienced, or problems encountered)

> **DO ...**

-   ...document any important information self-reported [by]{.underline}
    the recruiter about recruiting methods and techniques, barriers
    encountered, problems solved, etc.

> **DO NOT...**

-   ... document specific, detailed information about individual network
    associates on this page. Any information about a specific network
    associate should be documented on the Interview (Recruiters Only)-
    Network Associates page.

-   ... document staff comments/opinions about this recruiter, or issues
    that a staff member feels need to be documented about the recruiter.
    That information should be documented on the Notes (All
    Participants) page.

#### *Example*

  ------------------------------------ ----------------------------------
  Participant ID \# : 1-13             

  ------------------------------------ ----------------------------------

**Section III. Interview (Recruiters Only)**

**C. General Recruiter Issues**

+------+--------+-----------------------------------------------------+
| Date | Pr     | Issues reported [by recruiter]{.underline}          |
|      | ovider |                                                     |
|      |        |                                                     |
|      | ID \#  |                                                     |
+------+--------+-----------------------------------------------------+
| 8/2/ | 4101   | Recruiter called to report that he was having       |
| 2007 |        | trouble bringing up the topic of HIV and            |
|      |        | unprotected sex with a couple of his network        |
|      |        | associates. He said he was worried about people     |
|      |        | finding out he was positive. Provider ID# 98 and I  |
|      |        | discussed strategies for approaching network        |
|      |        | associates with him.                                |
+------+--------+-----------------------------------------------------+
| 8    | 501    | Recruiter stopped by to talk about one network      |
| /10/ |        | associate who he had talked with several times      |
| 2007 |        | (interview record \# 1-13-10) but he felt like he   |
|      |        | was not making progress with him. After discussing  |
|      |        | different strategies, he and I agreed that he       |
|      |        | should attend HIV 101 orientation session again and |
|      |        | review the class materials.                         |
+------+--------+-----------------------------------------------------+
| 8    | 501    | Recruiter called to report that he had gotten in a  |
| /23/ |        | dispute with one of his network associates          |
| 2007 |        | (interview record \# 1-13-8) and the man had        |
|      |        | threatened him with physical violence. We agreed    |
|      |        | that he should stay away from the man and not try   |
|      |        | to talk with him further.                           |
+------+--------+-----------------------------------------------------+

## Recruitment Method Page (Associates Only)

[When to enter data on this page]{.underline}

-   This page should be completed [for network associates
    only]{.underline}

-   This page should be completed when the network associate reports for
    testing (the first HIV test)

### *Field descriptions*

> **Participant ID \# (Associate)**

-   Unique ID \# assigned to each program participant

> **Date of CTR**

-   Date on which the CTR event was initiated (or when this page was
    completed)

> **Provider ID \# (CTR event initiated by)**

-   ID \# of the staff member who completed this page

> **How was network associate recruited? (select only one)**

-   Select the method by which the network associate was ultimately
    convinced to get tested for HIV

    -   *Directly through a recruiter (person is a direct network
        associate)*- Associate was recruited (identified) by a recruiter
        -- he/she is therefore a direct network associate

> *Enter Participant ID# of recruiter*- Document ID# of recruiter

-   *Indirectly through another (direct) network associate (person is an
    indirect network associate)*- Associate was recruited by a direct
    network associate

> *Enter Participant ID# of direct network associate*-Document ID# of
> the direct network associate that recruited this person
>
> *Enter Participant ID# of recruiter who recruited the direct network
> associate*- Document ID# of the recruiter who recruited the direct
> network associate above
>
> *Explain how the indirect network associate was identified (the
> circumstances)*- Provide details about how this person was identified
> and the circumstances surrounding how the person was found and tested.
> Be explicit so it will be clear which individuals should be linked.
>
> **Method for obtaining CTR**

-   Method by which associate received CTR

    -   *Escort* = Associate was escorted by a recruiter to the test
        site

    -   *Field test =* Associate was tested in the field

    -   *Referral to CTR site =* Associate was initially given
        information about testing and he/she later went to the testing
        site without being escorted)

### *Example #1*

  ------------------------------------- ---------------------------------
  Participant ID \# (Associate): 1-26   Date of CTR: 8/15/2007

  Provider ID \# (CTR event initiated   
  by): 501                              
  ------------------------------------- ---------------------------------

**Section IV. Recruitment Method (Associates Only)** **\[\*Complete this
section for 1^st^ HIV test only\]**

1.  How was network associate recruited? (select only one)

>  Directly through a recruiter (person is a direct network associate)
>
> Enter Participant ID \# of recruiter: 1-13
>
> ⁪ Indirectly through another (direct) network associate (person is an
> indirect network associate)
>
> Enter Participant ID \# of direct network associate:
> \_\_\_\_\_\_\_\_\_\_\_\_\_
>
> Enter Participant ID \# of recruiter who recruited the direct network
> associate: \_\_\_\_\_\_\_\_\_\_\_\_
>
> Explain how the indirect network associate was identified (the
> circumstances):
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

2.  Method for obtaining CTR: ⁪ Escort

⁪Field test

 Referral to CTR site

### *Example #2*

  ------------------------------------- ---------------------------------
  Participant ID \# (Associate): 1-42   Date of CTR: 9/25/2007

  Provider ID \# (CTR event initiated   
  by): 501                              
  ------------------------------------- ---------------------------------

**Section IV. Recruitment Method (Associates Only)** **\[\*Complete this
section for 1^st^ HIV test only\]**

1.  How was network associate recruited? (select only one)

> ⁪ Directly through a recruiter (person is a direct network associate)
>
> Enter Participant ID \# of recruiter:
>
>  Indirectly through another (direct) network associate (person is an
> indirect network associate)
>
> Enter Participant ID \# of direct network associate: 1-38
>
> Enter Participant ID \# of recruiter who recruited the direct network
> associate: 1-13
>
> Explain how the indirect network associate was identified (the
> circumstances):
>
> 1-42 was a friend of 1-38. After 1-38 got tested in August, he talked
> with some of his friends about HIV and several of them decided to get
> tested also. 1-42 was one of these people.

2.  Method for obtaining CTR: ⁪ Escort

⁪Field test

 Referral to CTR site

##  CTR Information Page (For Any Participant Tested)

[When to enter data on this page]{.underline}

-   This section should be completed [for any participant
    tested]{.underline}

-   A new section should be completed for each CTR event

### *Field descriptions*

> **Participant ID \#**

-   Unique ID \# assigned to each program participant

> **Date CTR event initiated**

-   Date on which the CTR event was initiated

> **Provider ID \# (CTR event initiated by)**

-   ID \# of the staff member who reported the recruiter issue

**[Reason for test:]{.underline}**

> **What was the reason for the test?**

-   Reason why test was given (*First* *test for Social Networks*,
    *Follow-up test*, or *Other reason*)

-   Optional- If *First test for Social Networks* is selected, a reason
    for testing may be specified

-   If *Follow-up test* is selected, select one of the following
    reasons:

> *Exposure within 3 months of previous test*
>
> *High-risk behaviors within 12 months of previous test*
>
> *STD within 12 months of previous test*
>
> *Previous test result indeterminate (standard)*
>
> *Previous test result invalid (rapid)*

-   If *Other reason* is selected, specify the reason

**[Risks:]{.underline}**

> **Behaviors within last year (select all that apply)**

-   Risk behaviors reported by participant in the past 3 months (*Within
    last 3 months*) and in the past year (*Within last 12 months*)

-   Select all risk behaviors that apply. If the participant does not
    identify or acknowledge any risks, select *No
    identified/acknowledged risk*.

-   If *Other risk* is selected, specify other risk (this field should
    only be used for risks not captured by other fields).

> **STD diagnosis in past 12 months?**

-   Has participant had an STD diagnosis in past 12 months?

-   Select Yes (*Yes*), No (*No*), or Unknown (*Unknown*).

> **IMPORTANT!**
>
> A person is considered "high-risk" if he/she has engaged in one or
> more of any of the risk behaviors OR has been diagnosed with an STD in
> the past 12 months.

**[Test selection:]{.underline}**

> **Did client agree to test?**

-   Did participant agree to test?

-   Select Yes (*Yes*) or No (*No*)

-   If *No*, go to Referrals page.

> **Test setting**

-   Type of test setting (*Confidential* or *Anonymous*)

> **Test type**

-   Test type (Rapid or Standard)

-   If *Standard*, go to Standard Testing page

-   If *Rapid*, go to Rapid Testing page.

**[Rapid testing:]{.underline}**

> **Rapid test done?**

-   Was a rapid HIV test given?

-   Select Yes (*Yes*) or No (*No*)

> **Rapid test date**

-   Date the test was given

> **Rapid test location**

-   Location where test was given: at your agency or another testing
    site (*CTR site*) or the test was given individually to the
    participant in the field (*Individual test in field*)

-   If *CTR site*, provide Site name and Site ID \#

> **Rapid test result**

-   Test result (*Preliminary* *positive, Negative, Invalid,* or
    *Unknown*)

> **IMPORTANT!**

-   All preliminary positive test results should be reported to the
    Health Dept. per state and local regulations.

-   If the result is negative, and there is either known/possible
    exposure within last 3 months OR high-risk behavior or STD within
    last 12 months, schedule a follow-up test.

> **Rapid test results provided to client?**

-   Were the test results provided to the client?

-   Select Yes (*Yes*) or No (*No*)

-   If *Yes*, specify the date provided

-   If *No*, specify reason why results were not provided

**[Confirmatory testing:]{.underline}**

> **Confirmatory test done?**

-   Was a confirmatory HIV test given?

-   Select Yes (*Yes*), No (*No*), or Unknown (*Unknown*)

-   If *No*, specify reason

> **Confirmatory test date**

-   Date the test was given

> **Confirmatory test location**

-   Location where test was given: at your agency or another testing
    site (*CTR site*) or the test was given individually to the
    participant in the field (*Individual test in field*)

-   If *CTR site*, provide Site name and Site ID \#

> **Confirmatory test result**

-   Test result (*Positive, Negative, Indeterminate,* or *Unknown*)

> **Confirmatory test results provided to client?**

-   Were the test results provided to the client?

-   Select Yes (*Yes*) or No (*No*)

-   If *Yes*, specify the date provided

-   If *No*, specify reason why results were not provided

**[Standard testing:]{.underline}**

> **Standard test done?**

-   Was a standard HIV test given?

-   Select Yes (*Yes*) or No (*No*)

-   If *No*, specify reason

> **Standard test date**

-   Date the test was given

> **Standard test location**

-   Location where test was given: at your agency or another testing
    site (*CTR site*) or the test was given individually to the
    participant in the field (*Individual test in field*)

-   If *CTR site*, provide Site name and Site ID \#

> **Standard test result**

-   Test result (*Positive, Negative, Indeterminate,* or *Unknown*)

> **Standard test results provided to client?**

-   Were the test results provided to the client?

-   Select Yes (*Yes*) or No (*No*)

-   If *Yes*, specify the date provided

-   If *No*, specify reason why results were not provided

> **IMPORTANT!**

-   All preliminary positive and positive test results should be
    reported to the Health Dept. per state and local regulations.

-   If the result for either test is negative, and there is either
    known/possible exposure within last 3 months OR high-risk behavior
    or STD within last 12 months, schedule a follow-up test.

-   If first indeterminate test, schedule a follow-up test.

**[Referrals:]{.underline}**

> **Referrals made?**

-   Were referrals made to participant (i.e., were referrals
    [offered]{.underline} to the participant)?

-   Select Yes (*Yes*) or No (*No*)

> **If referrals were made, indicate the specific referrals made (select
> all that apply) and the status of each referral**

-   Specific referrals that were made to the participant and the status
    of each referral

    -   *Not completed-* referral not yet completed

    -   *Completed and confirmed*- referral completed and confirmed by
        provider (not just self reported)

    -   *Unknown*- status of referral is unknown

    -   *Declined*- specific referral was made to the participant but
        he/she declined to accept it

**[Scheduling of follow-up testing:]{.underline}**

> **Follow-up test scheduled?**

-   Was a follow-up test scheduled?

-   Select Yes (*Yes*), No (*No*), or Unknown (*Unknown*)

-   If *Yes*, specify the date of the follow-up test

-   If *No*, specify the reason why a follow-up test was not scheduled.

> **If Yes, what was the reason?**

-   If a follow-up test was scheduled, the reason it was scheduled

    -   *Exposure within 3 months of current test*

    -   *High-risk behaviors within 12 months of current test*

    -   *STD within 12 months of current test*

    -   *Current test indeterminate (standard)*

    -   *Current test invalid (rapid)*

    -   *Other reason*

-   If Other reason, specify reason

> **If follow-up test was scheduled, what is the status of the test?**

-   Follow-up test status (*Follow-up test done, Follow-up test not yet
    done,* or *Unknown*)

-   Update this item as the status changes

**[Recruiter eligibility:]{.underline}**

> **Did you screen the recruiter to be a recruiter?**

-   Was this person screened by staff to determine if he/she could be a
    recruiter (i.e., screened to determine if the person meets the
    necessary criteria that would allow him/her to be invited to be a
    recruiter)?

-   Select Yes (*Yes*), No (*No*), or Unknown (*Unknown*)

-   If *No* or *Unknown*, specify reason

> **Did the associate meet the criteria?**

-   Did the person meet your site's requirements for being a recruiter?
    These criteria could be based on gender, race/ethnicity, risk group,
    etc.

-   Select Yes (*Yes*) or No (*No*)

-   If *No*, specify reason.

> **If the associate met the criteria, was he/she invited to be a
> recruiter? (All associates invited to be a recruiter should be entered
> in the Recruiter Enlistment/Orientation Log.)**

-   If the person met your site's recruiter criteria, was he/she invited
    to be a recruiter?

-   Select Yes (*Yes*) or No (*No*)

-   If *No*, specify reason.

### *Example*

  ------------------------------------ ----------------------------------
  Participant ID \# : 1-13             Date CTR event initiated:
                                       6/10/2007

  Provider ID \# (CTR event initiated  
  by): 4101                            
  ------------------------------------ ----------------------------------

**Section V. CTR Information (For Any Participant Tested)**

**A. Reason for Test**

1.  What was the reason for the test?  First test for Social Networks

Reason: Recently had sex with person who is possibly IDU

Follow-up test

> ⁪ Exposure within 3 months of previous test
>
> ⁪ High-risk behaviors within 12 months of previous test
>
> ⁪ STD within 12 months of previous test
>
> ⁪ Previous test result indeterminate (standard)
>
> ⁪ Previous test result invalid (rapid)
>
> ⁪ Other reason:
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**B. Risks**

1.  Behaviors within last year (select all that apply):

> Within last Within last
>
> [3 months]{.underline} [12 months]{.underline}
>
> Unprotected sex (oral, vaginal, anal) with:

Person with HIV or AIDS ⁪ ⁪

> Person of unknown HIV status, with known risk  
>
> Person of unknown HIV status, without known risk ⁪ ⁪
>
> Shared drug injection equipment (needle, syringe,
>
> cotton, cooker, water) after:
>
> Person with HIV or AIDS ⁪ ⁪
>
> Person with unknown HIV status, with known risk ⁪ ⁪
>
> Person with unknown HIV status, without known risk ⁪ ⁪
>
> Sex in exchange for money or drugs ⁪ ⁪
>
> Other
> risks:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
> ⁪ ⁪
>
> **[No]{.underline}** identified/acknowledged risk ⁪ ⁪

2.  STD diagnosis in past 12 months? ⁪ Yes

>  No
>
> ⁪ Unknown

**C. Test Selection**

1.  Did client agree to test?  Yes

> ⁪ No **(If No, go to Referrals Section)**

2.  Test setting:  Confidential

⁪Anonymous

3.  Test type:  Rapid **(If Rapid, go to Rapid Testing Section)**

⁪Standard **(If Standard, go to Standard Testing Section)**

  ----------------------------------- -----------------------------------
  Participant ID \# : 1-13            Date CTR event initiated: 6/10/2007

  Provider ID \# (CTR Event initiated 
  by): 4101                           
  ----------------------------------- -----------------------------------

**Section V. CTR Information (For Any Participant Tested)**

**D. Rapid Testing**

1.  Rapid test done?  Yes

⁪No

2.  Rapid test date: 6/10/2007

3.  Rapid test location:  CTR site

(Site name: Buckhead Site ID #: 3467 )

⁪Individual test in field

4.  Rapid test result:  Preliminary positive *(Report to Health Dept.
    per state/local regulations)*

⁪Negative *(Schedule follow-up test if either known/possible exposure
within*

*last 3 months OR high-risk behavior or STD within last 12 months)* ⁪
Invalid

⁪Unknown

5.  Rapid test results provided to client?  Yes (Date:
    6[/]{.underline}10/2007)

⁪No (Reason:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_)

6.  Confirmatory test done?  Yes

⁪No (Reason:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_)

⁪Unknown

7.  Confirmatory test date: [6/10/2007]{.underline}

8.  Confirmatory test location:  CTR site

(Site name: Buckhead Site ID #: 3467 )

⁪Individual test in field

9.  Confirmatory test result:  Positive *(Report to Health Dept. per
    state/local regulations)*

⁪Negative *(Schedule follow-up test if either known/possible exposure*

*within last 3 months OR high-risk behavior or STD within last 12
months)* ⁪ Indeterminate *(If first indeterminate test, schedule
follow-up test)*

⁪Unknown

10. Confirmatory test results provided to client?  Yes (Date: 6/17/2007
    )

⁪No (Reason: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_)

  ---------------------------------- ------------------------------------
  Participant ID \# : 1-13           Date CTR event initiated: 6/10/2007

  Provider ID \# (CTR Event          
  initiated by): 4101                
  ---------------------------------- ------------------------------------

**Section V. CTR Information (For Any Participant Tested)**

**E. Standard Testing**

1.  Standard test done? ⁪ Yes

⁪No

2.  Standard test date: \_\_ \_\_/\_\_ \_\_/\_\_ \_\_ \_\_ \_\_

3.  Standard test location: ⁪ CTR site

> (Site name: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Site
> ID #: \_\_\_\_\_\_\_\_\_\_\_\_\_)
>
> ⁪ Individual test in field

4.  Standard test result: ⁪ Positive *(Report to Health Dept. per
    state/local regulations)*

⁪Negative *(Schedule follow-up test if either known/possible exposure
within*

*last 3 months OR high-risk behavior or STD within last 12 months)*

⁪Indeterminate *(If first indeterminate test, schedule follow-up test)*

⁪Unknown

5.  Standard test results provided to client? ⁪ Yes (Date: \_\_ \_\_/\_\_
    \_\_/\_\_ \_\_ \_\_ \_\_)

⁪No (Reason: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_)

  ---------------------------------- ------------------------------------
  Participant ID \# : 1-13           Date CTR event initiated: 6/10/2007

  Provider ID \# (CTR Event          
  initiated by): 4101                
  ---------------------------------- ------------------------------------

**Section V. CTR Information (For Any Participant Tested)**

**F. Referrals**

1.  Referrals made?  Yes

> ⁪ No

2.  If referrals were made, indicate the specific referrals made (select
    all that apply) and the status of each referral:

  -----------------------------------------------------------------------
  **Status of referrals made**

  -----------------------------------------------------------------------

> **Referrals** Completed and

**Made** [Not completed]{.underline} c[onfirmed]{.underline}
[Unknown]{.underline} [Declined]{.underline}

>  HIV medical evaluation/management ⁪  ⁪ ⁪
>
> ⁪ HIV case management ⁪ ⁪ ⁪ ⁪
>
>  PCRS ⁪  ⁪ ⁪
>
> ⁪ HIV prevention case management ⁪ ⁪ ⁪ ⁪
>
> ⁪ Other HIV prevention counseling/services ⁪ ⁪ ⁪ ⁪
>
> ⁪ STD screening/treatment ⁪ ⁪ ⁪ ⁪
>
>  Drug or alcohol prevention/treatment  ⁪ ⁪ ⁪
>
> ⁪ Mental health services ⁪ ⁪ ⁪ ⁪
>
> ⁪ Viral hepatitis screening/vaccination/treatment ⁪ ⁪ ⁪ ⁪
>
>  Reproductive health services ⁪ ⁪ ⁪ 
>
> ⁪ Other medical evaluation/management ⁪ ⁪ ⁪ ⁪

*Notes:*

> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

  ----------------------------------- -----------------------------------
  Participant ID \# : 1-13            Date CTR event initiated: 6/10/2007

  Provider ID \# (CTR Event initiated 
  by): 4101                           
  ----------------------------------- -----------------------------------

**Section V. CTR Information (For Any Participant Tested)**

**G. Scheduling of Follow-up Testing**

1.  Follow-up test scheduled? ⁪ Yes (Date: )

>  No (Reason: Person is positive)
>
> ⁪ Unknown

2.  If Yes, what was the reason?

> ⁪ Exposure within 3 months of current test

⁪High-risk behavior within 12 months of current test

⁪STD within 12 months of current test

⁪Current test indeterminate (standard)

⁪Current test invalid (rapid)

⁪Other reason:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

3.  If follow-up test was scheduled, what is the status of the test?

> ⁪ Follow-up test done

⁪Follow-up test [not]{.underline} yet done

⁪Unknown

**H. Recruiter Eligibility**

1.  Did you screen the associate to be a recruiter?

>  Yes
>
> ⁪ No (Reason:
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_)
>
> ⁪ Unknown (Reason:
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_)

2.  Did the associate meet the criteria?

>  Yes
>
> ⁪ No (Reason:
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_)

3.  If the associate met the criteria, was he/she invited to be a
    recruiter? (All associates invited to be a recruiter must be entered
    in the Recruiter Enlistment/Orientation Log.)

>  Yes
>
> ⁪ No (Reason:
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_)

## Notes Page (All Participants)

[When to enter data on this page]{.underline}

-   This section should be completed, as needed, for all participants

-   Any general issues observed or experienced by the provider should be
    documented here (i.e., any issues or comments that a provider wants
    to document about a participant).

### *Field descriptions*

> **Participant ID \#**

-   Unique ID \# assigned to each program participant

> **Date**

-   Date on which the issue was documented

> **Provider ID \#**

-   ID \# of the staff member who documented the issue

> **Notes (Issues reported [by provider]{.underline} about this
> participant**

-   General information a staff member wishes to document about a
    particular participant

> **IMPORTANT!**

-   Record anything that seems important for understanding this person's
    role in the program.

-   Record anything related to how this person's participant data should
    be interpreted.

-   All information reported here should be from the provider's
    perspective (as opposed to using this page to document issues that
    are self-reported by the recruiter).

-   Any information self-reported by the recruiter about his personal
    experiences with general recruiting, methods and techniques,
    barriers encountered, problems solved, etc., should
    [not]{.underline} be reported here. That information should be
    reported on the Interview (Recruiters Only)- General Recruiter
    Issues page.

### *Example*

  ------------------------------------ ----------------------------------
  Participant ID #: 1-13               

  ------------------------------------ ----------------------------------

**Section VI. Notes (All Participants)**

+-------+--------+-----------------------------------------------------+
| Date  | Pr     | Notes (Issues reported [by provider]{.underline}    |
|       | ovider | about this participant)                             |
|       |        |                                                     |
|       | ID \#  |                                                     |
+-------+--------+-----------------------------------------------------+
| 6/12  | 4101   | This person might make a good recruiter given the   |
| /2007 |        | apparent size of his social network. When we follow |
|       |        | up with him about referrals in mid-June, we will    |
|       |        | approach the idea with him.                         |
+-------+--------+-----------------------------------------------------+
| 6/19  | 4101   | Before referral follow-up, I discussed timing of    |
| /2007 |        | inviting this person to be a recruiter with other   |
|       |        | staff members; we decided to wait a month, given    |
|       |        | his mental state and current physical health.       |
+-------+--------+-----------------------------------------------------+

# SECTION FIVE: BLANK DATA COLLECTION FORMS 

> Blank data collection forms are provided in this section. The forms
> may be modified to fit your program as needed.

***Social Networks Testing - Participant Data Form***

  -------------------------------------------------------- ---------------------------------
  Participant ID #:                                        Date: \_\_ \_\_/\_\_ \_\_/\_\_
  \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_   \_\_ \_\_ \_\_

  Provider ID \# (Intake performed by):                    
  \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                 
  -------------------------------------------------------- ---------------------------------

**Section I. General Information (All Participants)**

+-----------------------------------+----------------------------------+
| 5.  Participant type:             |                                  |
+-----------------------------------+----------------------------------+
| > ⁪ Recruiter                      | ⁪Direct network associate         |
+-----------------------------------+----------------------------------+
| > Continued past orientation? ⁪    | > Date of 1^st^ encounter: \_\_  |
| > Yes                             | > \_\_/\_\_ \_\_/\_\_ \_\_ \_\_  |
|                                   | > \_\_                           |
+-----------------------------------+----------------------------------+
| > ⁪ No                             |                                  |
+-----------------------------------+----------------------------------+
| 1^st^ Enlisted date: \_ \_/\_     | ⁪Indirect network associate       |
| \_/\_ \_ \_ \_ 1^st^ End date: \_ |                                  |
| \_/\_ \_/\_ \_ \_ \_              |                                  |
+-----------------------------------+----------------------------------+
|                                   | > Date of 1^st^ encounter: \_\_  |
|                                   | > \_\_/\_\_ \_\_/\_\_ \_\_ \_\_  |
|                                   | > \_\_                           |
+-----------------------------------+----------------------------------+
| 2^nd^ Enlisted date: \_ \_/\_     |                                  |
| \_/\_ \_ \_ \_ 2^nd^ End date: \_ |                                  |
| \_/\_ \_/\_ \_ \_ \_              |                                  |
+-----------------------------------+----------------------------------+
|                                   |                                  |
+-----------------------------------+----------------------------------+
| 3^rd^ Enlisted date: \_ \_/\_     |                                  |
| \_/\_ \_ \_ \_ 3^rd^ End date: \_ |                                  |
| \_/\_ \_/\_ \_ \_ \_              |                                  |
+-----------------------------------+----------------------------------+
|                                   |                                  |
+-----------------------------------+----------------------------------+

+---------------+---------------+--------------------+----------------+
| 6.            |               |                    |                |
| Demographics: |               |                    |                |
+---------------+---------------+--------------------+----------------+
| Gender:       | Ethnicity:    | Race:              | Date of birth: |
+---------------+---------------+--------------------+----------------+
| ⁪Male          | ⁪Hispanic or   | ⁪American           | \_\_ \_\_/\_\_ |
|               | Latino        | Indian/Alaskan     | \_\_/\_\_ \_\_ |
|               |               |                    | \_\_ \_\_      |
+---------------+---------------+--------------------+----------------+
| ⁪Female        | ⁪Not Hispanic  | Native             |                |
|               | or            |                    |                |
+---------------+---------------+--------------------+----------------+
| ⁪Transgender   | Latino        | ⁪Asian              |                |
+---------------+---------------+--------------------+----------------+
| ⁪Unknown       | ⁪Unknown       | ⁪Black/African      | Age (when      |
|               |               | American           | section was    |
+---------------+---------------+--------------------+----------------+
|               |               | ⁪Native             | completed):    |
|               |               | Hawaiian/Pacific   | \_\_\_\_\_\_\_ |
+---------------+---------------+--------------------+----------------+
|               |               | Islander           |                |
+---------------+---------------+--------------------+----------------+
|               |               | ⁪White              | Zip code:      |
|               |               |                    | \_\_\_\_\_     |
|               |               |                    | \_\_\_\_\_\_\_ |
+---------------+---------------+--------------------+----------------+
|               |               | ⁪                   |                |
|               |               | Other:\_\_\_\_     |                |
|               |               | \_\_\_\_\_\_\_\_\_ |                |
|               |               | \_\_\_\_\_\_\_\_\_ |                |
+---------------+---------------+--------------------+----------------+

7.  Risk group: ⁪ MSM

> ⁪ IDU
>
> ⁪ MSM/IDU
>
> ⁪ High-risk heterosexual (Heterosexual who engages in at least one risk
> behavior
>
> listed in Risks Section)
>
> ⁪ Unknown
>
> ⁪ Other risk group
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

8.  Marital status:

> ⁪ Single ⁪ Married ⁪ Divorced ⁪ Other status:
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> ⁪ Partnered ⁪ Separated ⁪ Declined ⁪ Unknown

  -------------------------------------- ---------------------------------------
  Participant ID #:                      
  \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_   

  -------------------------------------- ---------------------------------------

**Section II. Testing History (All Participants)**

> **At entry into Social Networks Testing program:**

  -------------------------------------- -------------------------------------
  Provider ID #:                         Date: \_\_ \_\_/\_\_ \_\_/\_\_ \_\_
  \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_   \_\_ \_\_

  -------------------------------------- -------------------------------------

4.  Has participant previously been tested? ⁪ Yes

> ⁪ No
>
> ⁪ Unknown

5.  If Yes, approximate date of most recent test (if known):

> \_\_ \_\_/\_\_ \_\_/\_\_ \_\_ \_\_ \_\_ ⁪ Unknown

6.  Result of most recent test:

[Rapid]{.underline} [Standard or Confirmatory]{.underline}

⁪Preliminary positive ⁪ Positive

⁪Negative ⁪ Negative

⁪Invalid ⁪ Indeterminate

⁪Unknown ⁪ Unknown

> *(Note: Preliminary positives/positives should be verified.)*
>
> **[If tested elsewhere after entry]{.underline} into Social Networks
> Testing program:**

  -------------------------------------- -------------------------------------
  Provider ID \# :                       Date: \_\_ \_\_/\_\_ \_\_/\_\_ \_\_
  \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_   \_\_ \_\_

  -------------------------------------- -------------------------------------

3.  Approximate date of test:

> \_\_ \_\_/\_\_ \_\_/\_\_ \_\_ \_\_ \_\_ ⁪ Unknown

4.  Test result:

[Rapid]{.underline} [Standard or Confirmatory]{.underline}

⁪Preliminary positive ⁪ Positive

⁪Negative ⁪ Negative

⁪Invalid ⁪ Indeterminate

⁪Unknown ⁪ Unknown

> *(Note: Preliminary positives/positives should be verified.)*

  -------------------------------------- ---------------------------------------------
  Participant ID \# (Recruiter):         
  \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_   

  -------------------------------------- ---------------------------------------------

**Section III. Interview (Recruiters Only)**

A. Network Associates

<table style="width:100%;">
<colgroup>
<col style="width: 6%" />
<col style="width: 9%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 19%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 7%" />
<col style="width: 5%" />
<col style="width: 6%" />
<col style="width: 5%" />
<col style="width: 6%" />
<col style="width: 9%" />
</colgroup>
<tbody>
<tr class="odd">
<td>Interview record #</td>
<td><p>Provider</p>
<p>ID # (Interviewer)</p></td>
<td>Date elicited</td>
<td>Name type*</td>
<td>Name</td>
<td colspan="3">Description</td>
<td>Previously recruited?</td>
<td><p>Date</p>
<p>contacted</p></td>
<td>Recruiter/ associate records linked?</td>
<td>Status+</td>
<td>Date closed</td>
<td><p>Participant</p>
<p>ID #</p>
<p>(Associate)</p></td>
</tr>
<tr class="even">
<td rowspan="4"></td>
<td rowspan="4"></td>
<td rowspan="4"></td>
<td rowspan="4">F P A</td>
<td>Last:</td>
<td rowspan="2">Age</td>
<td rowspan="2"><blockquote>
<p>Sex</p>
</blockquote></td>
<td rowspan="2"><blockquote>
<p>Race</p>
</blockquote></td>
<td rowspan="4">Y N</td>
<td rowspan="4"></td>
<td rowspan="4">Y N</td>
<td rowspan="4">O C</td>
<td rowspan="4"></td>
<td rowspan="4"></td>
</tr>
<tr class="odd">
<td rowspan="2">First:</td>
</tr>
<tr class="even">
<td rowspan="2">Ht.</td>
<td rowspan="2"><blockquote>
<p>Wt.</p>
</blockquote></td>
<td rowspan="2"><blockquote>
<p>Hair</p>
</blockquote></td>
</tr>
<tr class="odd">
<td>Nicknames/aliases:</td>
</tr>
<tr class="even">
<td colspan="14">Locating information:</td>
</tr>
<tr class="odd">
<td colspan="14"><em>Comments:</em></td>
</tr>
<tr class="even">
<td>Interview record #</td>
<td><p>Provider</p>
<p>ID # (Interviewer)</p></td>
<td>Date elicited</td>
<td>Name type*</td>
<td>Name</td>
<td colspan="3">Description</td>
<td>Previously recruited?</td>
<td><p>Date</p>
<p>contacted</p></td>
<td>Recruiter/ associate records linked?</td>
<td>Status+</td>
<td>Date closed</td>
<td><p>Participant</p>
<p>ID #</p>
<p>(Associate)</p></td>
</tr>
<tr class="odd">
<td rowspan="4"></td>
<td rowspan="4"></td>
<td rowspan="4"></td>
<td rowspan="4">F P A</td>
<td>Last:</td>
<td rowspan="2">Age</td>
<td rowspan="2"><blockquote>
<p>Sex</p>
</blockquote></td>
<td rowspan="2"><blockquote>
<p>Race</p>
</blockquote></td>
<td rowspan="4">Y N</td>
<td rowspan="4"></td>
<td rowspan="4">Y N</td>
<td rowspan="4">O C</td>
<td rowspan="4"></td>
<td rowspan="4"></td>
</tr>
<tr class="even">
<td rowspan="2">First:</td>
</tr>
<tr class="odd">
<td rowspan="2">Ht.</td>
<td rowspan="2"><blockquote>
<p>Wt.</p>
</blockquote></td>
<td rowspan="2"><blockquote>
<p>Hair</p>
</blockquote></td>
</tr>
<tr class="even">
<td>Nicknames/aliases:</td>
</tr>
<tr class="odd">
<td colspan="14">Locating information:</td>
</tr>
<tr class="even">
<td colspan="14"><em>Comments:</em></td>
</tr>
</tbody>
</table>

\* Name type: F=**[F]{.underline}**ull name is given, P=
**[P]{.underline}**artial name only is given, A = Person is
**[A]{.underline}**nonymous (i.e., recruiter does not give name)

\+ Status: O = **[O]{.underline}**pen, C = **[C]{.underline}**losed

  -------------------------------------- -----------------------------------
  Participant ID \# (Recruiter):         
  \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_   

  -------------------------------------- -----------------------------------

**Section III. Interview (Recruiters Only)**

**B. General Recruiter Issues**

+--------+-------+-----------------------------------------------------+
| Date   | Pro   | Issues reported [by recruiter]{.underline}          |
|        | vider |                                                     |
|        |       |                                                     |
|        | ID \# |                                                     |
+--------+-------+-----------------------------------------------------+
|        |       |                                                     |
+--------+-------+-----------------------------------------------------+
|        |       |                                                     |
+--------+-------+-----------------------------------------------------+
|        |       |                                                     |
+--------+-------+-----------------------------------------------------+
|        |       |                                                     |
+--------+-------+-----------------------------------------------------+
|        |       |                                                     |
+--------+-------+-----------------------------------------------------+
|        |       |                                                     |
+--------+-------+-----------------------------------------------------+
|        |       |                                                     |
+--------+-------+-----------------------------------------------------+
|        |       |                                                     |
+--------+-------+-----------------------------------------------------+
|        |       |                                                     |
+--------+-------+-----------------------------------------------------+
|        |       |                                                     |
+--------+-------+-----------------------------------------------------+
|        |       |                                                     |
+--------+-------+-----------------------------------------------------+
|        |       |                                                     |
+--------+-------+-----------------------------------------------------+

  ------------------------------------------------ ------------------------------------
  Participant ID \# (Associate):                   Date of CTR: \_\_ \_\_/\_\_
  \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_   \_\_/\_\_ \_\_ \_\_ \_\_

  Provider ID \# (CTR event initiated by):         
  \_\_\_\_\_\_\_\_\_\_\_\_\_\_                     
  ------------------------------------------------ ------------------------------------

**Section IV. Recruitment Method (Associates Only)** **\[\*Complete this
section for 1^st^ HIV test only\]**

1.  How was network associate recruited? (select only one)

> ⁪ Directly through a recruiter (person is a direct network associate)
>
> Enter Participant ID \# of recruiter: \_\_\_\_\_\_\_\_\_\_\_\_\_
>
> ⁪ Indirectly through another (direct) network associate (person is an
> indirect network associate)
>
> Enter Participant ID \# of direct network associate:
> \_\_\_\_\_\_\_\_\_\_\_\_\_
>
> Enter Participant ID \# of recruiter who recruited the direct network
> associate: \_\_\_\_\_\_\_\_\_\_\_\_\_
>
> Explain how the indirect network associate was identified (the
> circumstances):
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

3.  Method for obtaining CTR: ⁪ Escort

⁪Field test

⁪Referral to CTR site

  ------------------------------------------------------------ ------------------------------------
  Participant ID \# :                                          Date CTR event initiated: \_\_
  \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_   \_\_/\_\_ \_\_/\_\_ \_\_ \_\_ \_\_

  Provider ID \# (CTR event initiated by):                     
  \_\_\_\_\_\_\_\_\_\_\_\_\_\_                                 
  ------------------------------------------------------------ ------------------------------------

**Section V. CTR Information (For Any Participant Tested)**

**A. Reason for Test**

4.  What was the reason for the test? ⁪ First test for Social Networks

Reason:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

> Follow-up test
>
> ⁪ Exposure within 3 months of previous test
>
> ⁪ High-risk behaviors within 12 months of previous test
>
> ⁪ STD within 12 months of previous test
>
> ⁪ Previous test result indeterminate (standard)
>
> ⁪ Previous test result invalid (rapid)

⁪Other reason:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**B. Risks**

3.  Behaviors within last year (select all that apply):

> Within last Within last
>
> [3 months]{.underline} [12 months]{.underline}
>
> Unprotected sex (oral, vaginal, anal) with:

Person with HIV or AIDS ⁪ ⁪

> Person of unknown HIV status, with known risk ⁪ ⁪
>
> Person of unknown HIV status, without known risk ⁪ ⁪
>
> Shared drug injection equipment (needle, syringe,
>
> cotton, cooker, water) after:
>
> Person with HIV or AIDS ⁪ ⁪
>
> Person with unknown HIV status, with known risk ⁪ ⁪
>
> Person with unknown HIV status, without known risk ⁪ ⁪
>
> Sex in exchange for money or drugs ⁪ ⁪
>
> Other risks:
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
> ⁪ ⁪
>
> **[No]{.underline}** identified/acknowledged risk ⁪ ⁪

4.  STD diagnosis in past 12 months? ⁪ Yes

> ⁪ No
>
> ⁪ Unknown

**C. Test Selection**

4.  Did client agree to test? ⁪ Yes

> ⁪ No **(If No, go to Referrals Section)**

5.  Test setting: ⁪ Confidential

⁪Anonymous

6.  Test type: ⁪ Rapid **(If Rapid, go to Rapid Testing Section)**

⁪Standard **(If Standard, go to Standard Testing Section)**

  -------------------------------------- ------------------------------------
  Participant ID \# :                    Date CTR event initiated: \_\_
  \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_   \_\_/\_\_ \_\_/\_\_ \_\_ \_\_ \_\_

  Provider ID \# (CTR event initiated    
  by): \_\_\_\_\_\_\_\_\_\_\_\_\_\_      
  -------------------------------------- ------------------------------------

**Section V. CTR Information (For Any Participant Tested)**

**D. Rapid Testing**

10. Rapid test done? ⁪ Yes

⁪No

11. Rapid test date: \_\_ \_\_/\_\_ \_\_/\_\_ \_\_ \_\_ \_\_

12. Rapid test location: ⁪ CTR site

(Site name: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Site ID #:
\_\_\_\_\_\_\_\_\_\_\_)

⁪Individual test in field

13. Rapid test result: ⁪ Preliminary positive *(Report to Health Dept.
    per state/local regulations)*

⁪Negative *(Schedule follow-up test if either known/possible exposure
within last 3 months*

*OR high-risk behavior or STD within last 12 months)*

⁪Invalid

⁪Unknown

14. Rapid test results provided to client? ⁪ Yes (Date: \_\_ \_\_/\_\_
    \_\_/\_\_ \_\_ \_\_ \_\_)

⁪No (Reason:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_)

15. Confirmatory test done? ⁪ Yes

⁪No (Reason:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_)

⁪Unknown

16. Confirmatory test date: \_\_ \_\_/\_\_ \_\_/\_\_ \_\_ \_\_ \_\_

17. Confirmatory test location: ⁪ CTR site

(Site name: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Site ID #:
\_\_\_\_\_\_\_\_\_\_)

⁪Individual test in field

18. Confirmatory test result: ⁪ Positive *(Report to Health Dept. per
    state/local regulations)*

⁪Negative *(Schedule follow-up test if either known/possible exposure
within last 3*

*months OR high-risk behavior or STD within last 12 months)*

⁪Indeterminate *(If first indeterminate test, schedule follow-up test)*

⁪Unknown

11. Confirmatory test results provided to client? ⁪ Yes (Date: \_\_
    \_\_/\_\_ \_\_/\_\_ \_\_ \_\_ \_\_)

⁪No (Reason: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_)

  ---------------------------------------------------------- ------------------------------------
  Participant ID \# :                                        Date CTR event initiated: \_\_
  \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_   \_\_/\_\_ \_\_/\_\_ \_\_ \_\_ \_\_

  Provider ID \# (CTR event initiated by):                   
  \_\_\_\_\_\_\_\_\_\_\_\_\_\_                               
  ---------------------------------------------------------- ------------------------------------

**Section V. CTR Information (For Any Participant Tested)**

**E. Standard Testing**

6.  Standard test done? ⁪ Yes

⁪No

7.  Standard test date: \_\_ \_\_/\_\_ \_\_/\_\_ \_\_ \_\_ \_\_

8.  Standard test location: ⁪ CTR site

> (Site name: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Site
> ID #: \_\_\_\_\_\_\_\_\_\_\_\_\_)
>
> ⁪ Individual test in field

9.  Standard test result: ⁪ Positive *(Report to Health Dept. per
    state/local regulations)*

⁪Negative *(Schedule follow-up test if either known/possible exposure
within last 3*

*months OR high-risk behavior or STD within last 12 months)*

⁪Indeterminate *(If first indeterminate test, schedule follow-up test)*

⁪Unknown

10. Standard test results provided to client? ⁪ Yes (Date: \_\_ \_\_/\_\_
    \_\_/\_\_ \_\_ \_\_ \_\_)

⁪No (Reason: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_)

  -------------------------------------- ------------------------------------
  Participant ID \# :                    Date CTR event initiated: \_\_
  \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_   \_\_/\_\_ \_\_/\_\_ \_\_ \_\_ \_\_

  Provider ID \# (CTR event initiated    
  by): \_\_\_\_\_\_\_\_\_\_\_\_\_\_      
  -------------------------------------- ------------------------------------

**Section V. CTR Information (For Any Participant Tested)**

**F. Referrals**

3.  Referrals made? ⁪ Yes

> ⁪ No

4.  If referrals were made, indicate the specific referrals made (select
    all that apply) and the status of each referral:

  -----------------------------------------------------------------------
  **Status of referrals made**

  -----------------------------------------------------------------------

> **Referrals** Completed and

**made** [Not completed]{.underline} c[onfirmed]{.underline}
[Unknown]{.underline} [Declined]{.underline}

> ⁪ HIV medical evaluation/management ⁪ ⁪ ⁪ ⁪
>
> ⁪ HIV case management ⁪ ⁪ ⁪ ⁪
>
> ⁪ PCRS ⁪ ⁪ ⁪ ⁪
>
> ⁪ HIV prevention case management ⁪ ⁪ ⁪ ⁪
>
> ⁪ Other HIV prevention counseling/services ⁪ ⁪ ⁪ ⁪
>
> ⁪ STD screening/treatment ⁪ ⁪ ⁪ ⁪
>
> ⁪ Drug or alcohol prevention/treatment ⁪ ⁪ ⁪ ⁪
>
> ⁪ Mental health services ⁪ ⁪ ⁪ ⁪
>
> ⁪ Viral hepatitis screening/vaccination/treatment ⁪ ⁪ ⁪ ⁪
>
> ⁪ Reproductive health services ⁪ ⁪ ⁪ ⁪
>
> ⁪ Other medical evaluation/management ⁪ ⁪ ⁪ ⁪

*Notes:*

> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

  -------------------------------------- ------------------------------------
  Participant ID \# :                    Date CTR event initiated: \_\_
  \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_   \_\_/\_\_ \_\_/\_\_ \_\_ \_\_ \_\_

  Provider ID \# (CTR event initiated    
  by): \_\_\_\_\_\_\_\_\_\_\_\_\_\_      
  -------------------------------------- ------------------------------------

**Section V. CTR Information (For Any Participant Tested)**

**G. Scheduling of Follow-up Testing**

1.  Follow-up test scheduled? ⁪ Yes (Date: \_\_ \_\_/\_\_ \_\_/\_\_ \_\_
    \_\_ \_\_)

⁪No (Reason:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_)

> ⁪ Unknown

5.  If Yes, what was the reason?

> ⁪ Exposure within 3 months of current test

⁪High-risk behavior within 12 months of current test

⁪STD within 12 months of current test

⁪Current test indeterminate (standard)

⁪Current test invalid (rapid)

⁪Other reason:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

6.  If follow-up test was scheduled, what is the status of the test?

> ⁪ Follow-up test done

⁪Follow-up test [not]{.underline} yet done

⁪Unknown

**H. Recruiter Eligibility**

4.  Did you screen the associate to be a recruiter?

> ⁪ Yes
>
> ⁪ No (Reason:
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_)
>
> ⁪ Unknown (Reason:
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_)

5.  Did the associate meet the criteria?

> ⁪ Yes
>
> ⁪ No (Reason:
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_)

6.  If the associate met the criteria, was he/she invited to be a
    recruiter? (All associates invited to be a recruiter must be entered
    in the Recruiter Enlistment/Orientation Log.)

> ⁪ Yes
>
> ⁪ No (Reason:
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_)

  -------------------------------------- -----------------------------------
  Participant ID #:                      
  \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_   

  -------------------------------------- -----------------------------------

**Section VI. Notes (All Participants)**

+-------+-------+------------------------------------------------------+
| Date  | Pro   | Notes (Issues reported [by provider]{.underline}     |
|       | vider | about this participant)                              |
|       |       |                                                      |
|       | ID \# |                                                      |
+-------+-------+------------------------------------------------------+
|       |       |                                                      |
+-------+-------+------------------------------------------------------+
|       |       |                                                      |
+-------+-------+------------------------------------------------------+
|       |       |                                                      |
+-------+-------+------------------------------------------------------+
|       |       |                                                      |
+-------+-------+------------------------------------------------------+
|       |       |                                                      |
+-------+-------+------------------------------------------------------+
|       |       |                                                      |
+-------+-------+------------------------------------------------------+
|       |       |                                                      |
+-------+-------+------------------------------------------------------+
|       |       |                                                      |
+-------+-------+------------------------------------------------------+