Non-Response Data Collection Form

Attachment 2c. 2007 Non-Response Data Collection Form

NON-RESPONSE DATA COLLECTION FORM

[Completed by project staff]

VERSION 1.3

DEPARTMENT OF HEALTH AND HUMAN SERVICES

P

ublic Health Service

Centers for Disease Control and Prevention

Atlanta, GA 30333

Collect the following information for all persons selected for NIC who do not participate in the NIC interview. You may obtain this information from the HIV AIDS Reporting System (HARS) or any other surveillance database.

Never In Care (NIC) Identification No: ___ ___ ___ ___

Date Form Completed: ___ ___ / ___ ___ / ___ ___ ___ ____

m m d d y y y y

Data Sources:
	1	HARS
	2	Other (Specify:_________________)

Date of Birth: ___ ___ / ___ ___ / ___ ___ ___ ____

m m d d y y y y

First positive HIV antibody test:

Age: ___ ___ Date: ___ ___ / ___ ___ ___ ___

m m y y y y

First AIDS diagnosis:

Age: ___ ___ Date: ___ ___ / ___ ___ ___ ___

m m y y y y

Sex:	1	Male
	 2	Female

Ethnicity:

(select one)	1	Hispanic/Latino
	 2	Not Hispanic/ Not Latino
	 8	Unknown

Race:	 1	American Indian or Alaska Native
(select all that apply)	 2	Black or African American
	 3	Asian
	 4	Native Hawaiian or Other Pacific Islander
	 5	White
	 8	Unknown
Country of Birth:	 1	U.S.
	 2	U.S. Dependencies and Possessions (including Puerto Rico)
	 3	Other (Specify): __________________________________
	 8	Unknown

Mode of HIV Exposure	Yes	No	Unknown
Sex with male………………………………….	 1	 0	 8
Sex with female………………………………..	 1	 0	 8
Injected nonprescription drugs ………………..	 1	 0	 8
Heterosexual intravenous or injection drug user…………………………………………….	 1	 0	 8
Bisexual male …………………………………	 1	 0	 8
Person with hemophilia or coagulation disorder………………………………………...	 1	 0	 8
Person with AIDS or documented HIV, risk not specified …………………………….……	 1	 0	 8
Received transfusion from donor with documented HIV………………………………	 1	 0	 8
Received transplant from donor with documented HIV..…………………………….	 1	 0	 8
Received clotting factor ………………………	 1	 0	 8
Received transfusion of blood/blood components (other than clotting factor)……….	 1	 0	 8
Received transplant of tissue or organs or artificial insemination…………………………	 1	 0	 8
Worked in a health-care or clinical laboratory setting………………………..………………...	 1	 0	 8

First CD4 Test:

Count: ___, ___ ___ ___ Date: ___ ___ / ___ ___ ___ ____ Percent: ___ ___

m m y y y y

	Positive	Negative	Indeterminate	Not tested	Test Date
HIV-IEIA	 1	 2	 3	 4	__ __ / __ __ __ __ m m y y y y
HIV-1/HIV-2 Combination EIA	 1	 2	 3	 4	__ __ / __ __ __ __ m m y y y y
HIV-1 WB/IFA	 1	 2	 3	 4	__ __ / __ __ __ __ m m y y y y
Other HIV antibody test	 1	 2	 3	 4	__ __ / __ __ __ __ m m y y y y

4