HIV Early Intervention Services (EIS) Quarterly Activity Log (Version 10/01)

Field Report HIV Early Intervention Services (EIS) Part 1: Activity Log Rev 8/30/16 Center Name ______City/Town ______

Submitted by ______Phone ______

Cell Phone ______Email ______Circle Quarter: First July 1 – September 30 Year ______Due October 15 Second October 1 – December 31 Year ______Due January 15 Third January 1 – March 31 Year ______Due April 15

Fourth April 1 – June 30 Year ______Due July 15

1. Number of consumers who agreed to the Rapid HIV Test 2. Of those who took the rapid test, how many received Post Test Counseling (their results) ? 3. How many had a preliminary positive result? 4. No. of preliminary positive results that were confirmed 5. Number of consumers who agreed to a Blood Drawn HIV Test (not counting confirmatory tests). 6. Of those who took a blood drawn test, how many received Post Test Counseling? 7. No. of HIV positive test results from blood drawn testing (not counting rapid confirmatory tests). 8. Of the total no. of people tested this quarter, how many were tested at an outreach event? 9. How many people did you educate or engage at an outreach event this quarter? 10. Total number of consumers that you have newly diagnosed HIV-positive this quarter. * (Add line 4 + line 7) 11. Number of new self-identified HIV-positive consumers you worked with this quarter. * (Anyone who disclosed their HIV-positive status to you for the first time this quarter) 12. Number of people that you have newly diagnosed HIV-positive that you linked to services. (Of the number on line 10, how many did you link to services?) 13. Number of new self-identified HIV-positive consumers that you linked to services. (Of the number on line 11, how many did you link to services?) 14. Number of HIV-positive people that you serve ongoing . (HIV+ people who continue to return for support) 15. I submitted a Part 1 bubble sheet for every HIV test performed this quarter (circle one) Yes No 16. I submitted a Part 2 bubble sheet for each confirmed HIV+ test result this quarter Yes No 17. I submitted an HIV Positive Case Report form for each confirmed HIV+ test result this quarter.** Yes No 18. I included an HIV+ Consumer Served Today form for each HIV+ client served for the 1st time this Yes No quarter.* Send report to Katherine Bever [email protected] or Fax to 404-704-0699 * Fill out a confidential form: HIV-positive Consumer Served Today (one time only) for each HIV+ consumer that you serve (whether newly or previously diagnosed) & submit with this report. For a copy of the form, visit the FORMS page of www.hiveis.com. ** An HIV Case Report is required for each new HIV diagnosis; visit the FORMS page of www.hiveis.com for a copy. QUESTIONS? Call Marie Sutton at 404-874-4040 or Winona Holloway at 404.805.0369. 1 Quarterly HIV EIS Report continued Part 2: Narrative

We ask for a narrative because the numbers provided on page one do not tell the whole story. Please type. Use additional sheets as needed.

1. Serving HIV-Positive Clients If any newly diagnosed HIV-positive client was not linked to care, please explain.

Please describe any ongoing support that you provide to HIV-positive consumers.

2. Outreach - - Describe any outreach activities. If your outreach was part of a campaign (like We > AIDS, or a National HIV/AIDS Awareness Day) what was the name of the campaign?

3. Successes / Challenges - - Describe your successes and / or any challenges this quarter.

4. Goals - - What goals do you have for your HIV/EIS program?

5. What are you doing to meet those goals?

We are very interested in your program and read every word of each report.

Email report to [email protected].