Demographic and Risk Profile Data Collection Tool

Prevention with Positives Client Level DEMOGRAPHIC AND RISK PROFILE DATA COLLECTION TOOL . These are the data variables that you are required to collect and enter into EvaluationWeb for every client who participates in any and all PwP interventions (ILI, GLI, IRRC, PCM). . Collect this information for each client who is HIV positive. . Collect this information for each client who is the sexual and/or needle sharing partner of a person who is HIV positive. . You are not required to use or submit this tool. You may develop your own data collection tool.

For agency use only. Client names are not 1. Client Name: entered into EvaluationWeb or reported to CDC.

2. Client ID: Must be an ID that is unique to this client. Cannot contain any personally identifying info.

DEMOGRAPHIC DATA

3. Date Demographic Data Collected:

4. Year of Birth (if unknown, enter 1800): 5. Country of Birth:

6. State of Residence: 7. County of Residence:

8. Ethnicity: 9. Race (select all that apply): Hispanic or Latino American Indian or Alaska Native Declined to Answer Not Hispanic or Latino Asian Don’t Know Don’t Know Black or African American Not Asked Declined to Answer Native Hawaiian or Pacific Islander Not Asked White

10. Assigned Sex at Birth: 11. Current Gender: Male Male Female Female Not Asked Transgender - MTF Declined to Answer Transgender - FTM Transgender - Unspecified Not asked Declined to answer Other, please specify:

RISK PROFILE Date of the initial risk profile should be the intake date or first session. Additional risk 12. Date Risk Data Collected: profiles can be added at any time with a new date.

13. Previous HIV Test: 14. Self-Reported Result of Most Recent HIV Test: No If Yes, continue to 14. Positive Yes Any other response, Negative Not Asked skip to 15. Preliminary Positive Declined to Answer Indeterminate Don’t Know Not Asked Declined to Answer Don’t Know

15. Client Behavioral Risk Profile: Client completed risk profile If client completed risk profile, continue to 16. Client was not asked about risk factors Any other response, you do not need to complete No risk identified any further questions on this form. Client declined to discuss risk factors RISK PROFILE, continued Indicate whether or not the client self-reported any of the following risk behaviors in the past 12 months. 16. Vaginal or anal sex with a male Yes No Don’t Know Declined to Answer Not Asked If Yes, also respond to the following: Vaginal or anal sex without a condom with a male Yes No Don’t Know Declined to Answer Not Asked Vaginal or anal sex with a male IDU Yes No Don’t Know Declined to Answer Not Asked Vaginal or anal sex with HIV positive male Yes No Don’t Know Declined to Answer Not Asked Vaginal or anal sex with MSM Yes No Don’t Know Declined to Answer Not Asked (only for clients whose current gender is female or MTF)

17. Vaginal or anal sex with a female Yes No Don’t Know Declined to Answer Not Asked If Yes, also respond to the following: Vaginal or anal sex without a condom with a female Yes No Don’t Know Declined to Answer Not Asked Vaginal or anal sex with a female IDU Yes No Don’t Know Declined to Answer Not Asked Vaginal or anal sex with HIV positive female Yes No Don’t Know Declined to Answer Not Asked

18. Vaginal or anal sex with a transgender person Yes No Don’t Know Declined to Answer Not Asked If Yes, also respond to the following: Vaginal or anal sex without a condom with a Yes No Don’t Know Declined to Answer Not Asked transgender person Vaginal or anal sex with a transgender IDU Yes No Don’t Know Declined to Answer Not Asked Vaginal or anal sex with an HIV positive Yes No Don’t Know Declined to Answer Not Asked transgender person

19. Injection drug use Yes No Don’t Know Declined to Answer Not Asked If yes, also respond to the following: Share drug injection equipment Yes No Don’t Know Declined to Answer Not Asked

20. Additional Risk Factors If the client’s risk in the past 12 months involves anal or vaginal sexual activity, indicate whether the client also engaged in any of the following risk factors (select all that apply): Exchange sex for drugs, money or something they needed If client’s risk did not involve anal or Diagnosed with sexually transmitted disease (STD) vaginal sexual activity, do not complete this question. Sex with multiple partners Oral sex Unprotected vaginal or anal sex with a person who is an IDU Unprotected vaginal or anal sex with a person who is HIV positive Unprotected vaginal or anal sex in exchange for drugs, money or something they needed Unprotected vaginal or anal sex with person who exchanges sex for drugs or money Unprotected sex with multiple partners Sex while intoxicated or high on drugs Sex with person of unknown HIV status Sex with person who exchanges sex for drugs or money