HIV TESTINGHTSThe Department of Health (DOH) has an existing program for the prevention and control of the Human Immunodeficiency Virus (HIV) in thePhilippines. The Epidemiology Bureau (EB) of DOH is mandated by Republic Act 11166 & 11332 to collect information that will be used inplanning activities to help stop the spread of HIV and to support and treat those diagnosed with HIV. Your full cooperation is very importantto this program. Please answer all questions as honestly as possible.
ABOUT THE TEST
What is HIV testing?
An HIV test refers to a procedure used to identify if you have antibodies to HIV -- the virus that causes AIDS. A specimen, usually blood, and a DOH-Food and Drug
Administration (FDA)-registered diagnostic kit is needed to perform the test. The test may be performed by a trained/supervised healthcare worker or lay person, or by
oneself, depending on the modality.
If the first test (screening) is reactive, another test (confirmatory) will be done to make sure that the first test is confirmed to be positive. A positive test means you havebeen infected with HIV. A non-reactive or negative test means you are not infected or your body has not produced the sufficient level of antibodies (within window period)that can be detected by the HIV rapid diagnostic test kits. If you are non-reactive or negative, and had a recent exposure within the window period, you need to undergo
another test 4 weeks after your risk exposure.
Confidentiality of HIV TestingYour personal information and HIV test result is confidential adherent to the provisions of RA 11166 Philippine HIV and AIDS Policy Act, RA 10173 Data Privacy Act of2012 and its IRR of 2016.

INFORMED CONSENT
Verbal ConsentI, CLIENT / CHILD / PROXY CONSENT PROVIDER, was given
information about HIV, its testing process, and was able to ask
questions about HIV. I agree to undergo HIV testing.

(applicable for clients 15☐ y/o and above undergoing
either CBS or self-testing)Name and Signature

By providing my contact details, I am allowing the HTS provider to contact me on
updates regarding the services provided including but not limited to: test result,combination prevention services, and notification for retesting.

Contact Number:
Email address:

PERSONAL INFORMATION SHEET (HTS FORM)
All information given will be STRICTLY CONFIDENTIAL. Please fill out this form COMPLETELY and as honestly as possible. Pleasewrite in CAPITAL LETTERS and CHECK the appropriate boxes.
DEMOGRAPHIC DATA
1Test Date:
MonthDay

2

PhilHealth Number:-3

PhilSys Number:Year☐ Not enrolled in PhilHealth-☐ No PhilSys Number

Name (Full name)

4
First Name

Middle NameFirst 2 letters of mother's FIRST nameLast NameFirst 2 letters of father's FIRST nameSuffix (Jr, Sr, III, etc)

Birth order (i.e. among mother's children)

56Birth date:Month7Day

Sex (assigned at birth):Age:

Age in months (for less than 1 year old):

Gender identity:☐ ManYear☐ Male☐ Female☐ Woman ☐ Others:

Current Place of Residence:

City/Municipality:

Province:

Permanent Residence:

City/Municipality:

Province:

Place of Birth:

City/Municipality:

Province:

9Nationality: ☐ Filipino☐ Other, please specify:

10

Civil Status:

11

Are you currently living with a partner?

12

Are you currently pregnant? (for female clients only)8☐ Single☐ Married☐ No☐ Separated☐ Widowed☐ Yes

Number of children:☐ No☐ Divorced☐ Yes

EDUCATION & OCCUPATION
1314☐ No grade completed

Highest Education Attainment?

Are you currently in school?

☐ No☐ Pre-school☐ Elementary☐ Highschool☐ College☐ Yes

Are you currently working?
15☐ Yes. Current occupation (main source of income):☐ No. Previous occupation in the past 12 months:☐ No ☐ Yes☐ No☐ Yes, specify year of return from last contract:
Where were you based? ☐ On a ship
☐ LandDid you reside or work overseas/abroad in the past 5 years?
16

Did you work overseas/abroad?

What country did you last work in? (For seafarer, last port of exit)

PERSONAL INFORMATION SHEET (HTS FORM 2021)☐ Vocational☐ Post-GraduateHIV TESTINGHTS

You may answer this on your own or with assistance from a counselor or healthcare provider
HISTORY OF EXPOSURE / RISK ASSESSMENTAnswer all. Please check the appropriate column for each item, and provide history of risk if applicable.

History of sexual activity(oral/anal/vaginal)

Sex with a MALE*
Sex with a FEMALE**

NoYes☐☐☐☐☐ No☐ Do not know

Did your birth mother have HIV when you were born?

☐ Yes

Date of most recent
anal or neo/vaginal sex(MM/YYYY)

Date of most recent
CONDOMLESS anal or
neo/vaginal sex (MM/YYYY)________________________________________________________________________*Sex partners whose assigned sex at birth is MALE, including transgender and/or nonbinary

17**Sex partners whose assigned sex at birth is FEMALE, including transgender and/or nonbinary

Paid for sex (in cash or kind)
Received payment (cash or in kind) in exchange for sex
Had sex under the influence of drugs
Shared needles in injection of drugs
Received blood transfusion
Occupational exposure (needlestick/sharps)

NoYes☐☐☐☐☐☐☐☐☐☐☐☐

Date of most recentrisk (MM/YYYY)____________________________________________________________________________________________________________REASONS FOR HIV TESTING
Please check all that apply.

☐ Possible exposure to HIV18☐ Recommended by physician/nurse/midwife☐ Referred by a peer educator☐ Employment - Overseas/Abroad ☐ Requirement for insurance☐ Employment - Local/Philippines ☐ Other (please specify):☐ Received a text message/email encouraging me to get an HIV test
PREVIOUS HIV TEST

☐ No

Have you ever been tested for HIV before?
19☐ Yes. Date of most recent test?

Which HTS provider (facility ororganization) conducted the test?
What was the result?
☐ Reactive ☐ Non-reactiveMonthYear

City/Municipality:☐ Indeterminate☐ Was not able to get result

To be filled out by HTS PROVIDER only
MEDICAL HISTORY & CLINICAL PICTURE20Please check all that apply.
☐ Current TB patient☐ Diagnosed with other STIs
☐ With hepatitis C☐ With hepatitis B
Clinical Picture:21☐ Asymptomatic☐ Symptomatic☐ Taken PEP☐ Taking PrEP

Describe S/Sx:☐ No physician to do staging

World Health Organization (WHO) Staging:

TESTING DETAILS
22
23

Client type:(select one)

Mode of reach:(select all that apply)☐ Inpatient☐ Walk-in/outpatient☐ Persons Deprived of Liberty (PDL)☐ Mobile HTS / Outreach in physical venues. Specify venue:☐ Clinical reach☐ Refused HIV Testing☐ Accepted HIV Testing24☐ Online☐ Index testing

Social and sexual☐ network testing☐ Outreach in physical venues

Reason for refusal:

HIV testing modality:
Linkage:(choose all that apply)☐ Facility-based testing (FBT) ☐ Non-laboratory FBT ☐ Community-based ☐ Self-testingMonthsWeeks☐ Refer to ART☐ Advise for re-testing inSuggested date: (MM/DD/YYYY)☐ Refer for Confirmatory

Other services provided to client:25☐ HIV 101
☐ IEC materials☐ Risk reduction planning☐ Referred to PrEP or had given PEP☐ Other services:☐ Condoms, # distributed:☐ Lubricants, # distributed:☐ Offered social and sexual network testing (SSNT)☐ Accepted SSNT

Inventory Information
Brand of test kit used:
Number of test kit used:
Test kit lot number:
Expiration date (mm/dd/yyyy):

HTS PROVIDER DETAILSName of Testing Facility/Organization:
26

Complete Mailing Address:
Contact Numbers:

27

Primary HTS provider:

Email address:(select one)

☐ HIV Counsellor ☐ Medical Technologist☐ CBS Motivator ☐ Others:

Name & Signature of service provider:END

PERSONAL INFORMATION SHEET (HTS FORM 2021)