<p> Referral Tracking Form</p><p>Client ID: ______</p><p>A. Referral Code: ______</p><p>____/____/______B. Referral Date: mm dd yyyy  HIV testing  Prenatal care  HIV confirmatory test  HIV medical care/treatment  HIV prevention counseling  General medical care  STD screening/treatment  PCRS  Viral hepatitis screening/  PCM treatment/immunization  Other HIV prevention C. Referral Service Type:  TB testing services  Syringe exchange services  Mental health services  Substance abuse prevention  Other support services or treatment services (specify):______ IDU risk reduction services ______ Reproductive health services  Other services (specify): ______ None D. Referral Follow-up  Active referral Method:  Passive referral—agency verification (Choose only one)  Passive referral—client verification  Pending E. Referral Outcome:  Confirmed—accessed service (Choose only one)  Confirmed—did not access service  Lost to follow-up</p><p>F. Referral Close Date: ____/____/____ mm dd yyyy ______G. Referral Notes ______</p><p>Many Men, Many Voices Evaluation Field Guide—September 2008 1 Referral Tracking Form: Codes and Explanations</p><p>Create and enter a unique code that your agency will use to A Referral Code track the client’s referral to another agency. B Referral Date The date the referral was made.</p><p>Indicate the type of service to which the client is being C Referral Service Type referred. Indicate the method by which the referral will be verified. </p><p>Options include:  Active referral: Direct linkage (access) to a service provider Referral Follow-up D Method  Passive referral—agency verification: Confirmation that the client accessed services by the receiving agency  Passive referral—client verification: Confirmation by the client that he/she accessed services  None: No plan to verify the completion of this referral Indicate the status of the referral at the time of follow-up. </p><p>Options include:  Pending: The status of the referral can’t be confirmed or denied E Referral Outcome  Confirmed—accessed service  Confirmed—did not access service  Lost to follow-up: The provider has been unable to verify the status of the referral within 60 days of the referral date. A date indicating when the referral is confirmed or lost to F Referral Close Date follow-up. G Referral Notes (Optional) Additional notes about the referral.</p><p>Many Men, Many Voices Evaluation Field Guide—September 2008 2</p>