Form 0920-25-0177 Madison Clinic Data Collection

Form Approved

OMB No. 0920-1357

Expiration Date: XX\XX\XXXX

The Greater Access and Impact with NAT (GAIN) Study: Improving HIV Diagnosis, Linkage to Care, and Prevention Services with HIV Point-of-Care Nucleic Acid Tests (NATs)

Attachment 4h

Madison Clinic Data Collection

Public reporting burden of this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering, and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; Attn: OMB-PRA (0920-1357)

Basic Demography Form

MRN

MRN (H)

Sex

Age

Race

Insurance Name

Insurance Class

Ethnicity

Lab Results

Contact Date

Collected Date

HIV

HIV (Rapid)

HIV (RNA)

Creatinine

Hepatitis A

Hepatitis B

Hepatitis C

Toxoplasmosis

Gonorrhea/Chlamydia Site

Gonorrhea

Chlamydia

Syphilis

Medication Ordered

GAIN Madison Clinic Longitudinal

Page 3

Ordered Date

Encounter Type

Medication 1

Medication 1 (Frequency)

Medication 1 (Quantity)

Medication 1 (Refill)

Medication 1 (Directions)

Medication 2

Medication 2 (Frequency)

Medication 2 (Quantity)

Medication 2 (Refill)

Medication 2 (Directions)

Medication 3

Medication 3 (Frequency)

Medication 3 (Quantity)

Medication 3 (Refill)

Medication 3 (Directions)

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Medication 4

Medication 4 (Frequency)

Medication 4 (Quantity)

Medication 4 (Refill)

Medication 4 (Directions)

Medication 5

Medication 5 (Frequency)

Medication 5 (Quantity)

Medication 5 (Refill)

Medication 5 (Directions)

Medication 6

Medication 6 (Frequency)

Medication 6 (Quantity)

Medication 6 (Refill)

Medication 6 (Directions)