**Sample Eligibility Screener Template**

**^®G200^**Date \_\_\_/\_\_\_/20\_\_\_ **^®H09^**Worker ID \_\_\_\_\_
**^®G102^**Client ID\_\_\_\_\_\_\_\_\_\_\_\_\_

**^®H18^Recruitment Source** (Type of service agency was providing when
client was referred to intervention)

Counseling and Testing Health Communication / Public Information

PCRS Outreach

Health Education/Risk Reduction Intake/Screening

Other \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Don't know (Refer)

**^®H13^Recruitment Source** (How client learned about the intervention,
if no outreach or referrals?)

Agency Advertisement Self Partner

Family/Friend Other \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Don't
know

**\*Name of agency making referral** (if appropriate)
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Name** First;\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Middle
\_\_\_\_\_\_\_\_\_\_ Last:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**^®G124^Current ^®G123^Gender ^®G116^Race (Check all that apply)
^®G114^Ethnicity**

**Gender at Birth**

Male Male American Indian/Alaskan Native Hispanic/Latino

Female Female Asian Non-Hispanic

Transgender Black or African-American Refused to answer

MTF Native Hawaiian/Pacific Islander Don't know

FTM White

Other \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Refused to answer

Don't know

**^®G112^DOB**\_\_\_\_/\_\_\_\_/\_\_\_\_\_\_\_
**^®G113^Age**\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**^®G121^Do you speak English?** No Yes **^®G122^If no, what language?**
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Sexual Orientation ^\*G126^ Relationship Status Insurance**

Straight/Heterosexual Single / Never married
Private\_\_\_\_\_\_\_\_\_\_\_\_

Bisexual Married or partnered Medicaid

Lesbian/Homosexual/Gay Married but separated Medicare

Refused to answer Divorced VA

Don't know Widowed Uninsured

Other \_\_\_\_\_\_\_\_\_\_\_\_ Not asked Other
\_\_\_\_\_\_\_\_\_\_\_\_\_

Other \_\_\_\_\_\_\_\_\_\_\_\_\_ Refused to answer

Refused to answer

**[HIV STATUS AND TESTING HISTORY]{.underline}**

**^®G204^HIV test ^®G205^Result of ^®\ G206^If negative, year
^®\ G207^If positive, year of**

**before today? prior test? of most recent test first positive test**

No (Refer to testing) Positive \_\_\_\_/\_\_\_\_/\_\_\_\_\_\_
\_\_\_\_/\_\_\_\_\_/\_\_\_\_\_

Yes Negative Don't know Don't know

Refused to answer Refused to answer

Don't know (Refer) Don't know (Refer)

**I would like to collect information from you to see if you are
eligible for CRCS. I ask these questions of all clients. In the past 90
days,**

Don't

No Yes Decline Know

Have you shared unclean works (such as needles or syringes) with
someone?

**^®G211^**Have you had unprotected sex with anyone (male, female,
transgender)

**^®G212^** Have you had sex with someone whose HIV status you did not
know?

**^®G212^**Have you had sex with someone whose HIV status you knew was
different

from yours?

**^®G213^** Have you been diagnosed with Syphilis, Chlamydia, or
Gonorrhea?\....

**^®G212^** Have you had sex while high on drugs or alcohol?
\...\...\...\...\...\...\...\...\...\...\...\.....

**^®G212^** Have you exchanged sex for money, drugs, shelter,
etc.?\...\...\...\...\...\...\...\...\....

If you are HIV-positive and have been prescribed HIV medication, have
you had

trouble taking your HIV medication as prescribed by your
doctor?\...\...\...\...\...\.....

Other
(Agency-Specified):\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

 The client answered **" Yes " or " Don't know "** to
**\_\_\_\_\_\_\_\_** of the questions above.

**Is client eligible for CRCS?** No Yes

**If eligible,**

Was CRCS explained to client? No Yes

Was confidentiality explained to client? No Yes

Will client participate in CRCS? No Yes

Were consent/confidentiality forms signed? No Yes

Was client given a copy of the consent form? No Yes

**^®^ Did client enroll in CRCS?** No Yes

**If client enrolled:**

**Which language will CRCS be conducted in?**

> English Spanish Arabic Cambodian Cantonese
>
> Creole/French Farsi Haika Hindi Japanese
>
> Korean Lao Mandarin Russian Tagalog
>
> Thai Vietnamese Other (specify)
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**^®X703^ Was the client given a referral(s)?** No Yes: Name
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Does the client already have a case manager?**

No Yes Not Asked Refused to answer Don't know

**If yes, what is your**

Case manager's name
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Telephone number \_\_\_\_\_\_\_ -\_\_\_\_\_\_\_- \_\_\_\_\_\_\_\_\_\_\_

Agency
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Other names or nickname
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**Best address for contacting client**

Street\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

City\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

State\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Zip\_\_\_\_\_\_\_\_\_\_\_\_

**Can you be contacted by phone/email/other way?** Yes No

Home\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Work\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Cell\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Pager\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Email\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Other
(way)\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**If client did not enroll, please check all reasons that apply**

No Reason/ just didn't try/ not interested Staff was rude / insensitive

No time/too busy/put it off Language barrier

Did not like the agency Intake process too complicated

Agency hours not good Too much trouble / work

No transportation Confidentiality issues

Fear/anxiety Too ill to go

Lack of trust in provider Felt well /did not need service

Other \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**^®^ Length of time client has spent with counselor? \_\_\_\_\_
Minutes**

**CRCS Counselor Signature**
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ **Date**
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_