ADOLESCENT SPNS PROJECT

INTERVENTION FORM INSTRUCTIONS

Use a black writing instrument (pen or pencil) to complete this form. Answer questions by either filling in a circle, or writing a number or letter in a square box. If the answer goes in a square box, you must use a CAPITAL LETTER or number that does not touch the side of the box. Print only one letter or number in each box. Make the letter or number look like those in the boxes on the Instructions form. If they do not, the computer cannot read your answers. If the letters or numbers that you print touch the sides of the boxes, or if you do not clearly print the information, the computer will "kick out" the form and we will need to return it to you to be completed correctly. If the question asks the answer to be filled in a circle, make sure that the circle is completely darkened.

Specific Parts of the Intervention Form

SPNS SITE. This is a code to identify your project in the cross-cutting evaluation. It should be pre-printed on the form. If it has not been already entered on the form, check with your project to find out your site code and enter it in the boxes. Site codes are 2 or 3 letters.

PROVIDER. Enter the code for the service provider agency doing the activity. The provider codes are on a separate sheet. Provider codes are 2 or 3 letters.

STAFF CODE. Enter the staff member code or codes for each of the staff providing services. The staff codes are on a separate sheet. If there is a combination of 2 or more staff members providing the service, the staff codes for combinations of staff should be used. Staff codes are 3 numbers.

SERVICE DATE. Enter the numbers representing today's date (the date of the activity) in these boxes. Enter the month as a number from 01 to 12 for January through December. Enter the day as a two-digit number (01 to 31). Enter the last two digits of the current year (for example, "94" for 1994). Make sure that if a month or day is less than 10, you place a "0" before the number.

HOUR. Enter the approximate time that the activity started in these boxes. Use a "0" as a place holder if you use a number less than 10. Then darken the circle to indicate AM or PM. For example, if the activity occurred at 1:30 in the afternoon, enter "01" for Hour and darken the circle next to "PM." Round the time to the nearest hour. For example, 12:31 to 1:30 is entered as "01" to indicate 1:00. Do not enter the time in military or 24-hour format (such as 13:00).

LENGTH MINUTES. Enter the number of minutes that the activity lasted in these three boxes. If the activity lasted less than 100 minutes, enter a "0" before the number of minutes. For example, if the activity lasted 25 minutes, you would enter "025"; if it lasted 5 minutes, you would enter "005."

CLIENT CODE. If your site is using the unique identifier proposed by The Measurement Group, print the first and last initials of the person you have contacted in the first two boxes. If he or she does not want to tell you his/her initials, leave these boxes blank. Leave the rest of the boxes for "CLIENT CODE" blank.

If your site is not using the unique identifier proposed by The Measurement Group, use the boxes next to "CLIENT CODE" to enter the unique identifier your site is using. See specific instructions for your site.

GENDER. Darken the circle next to "Male" or "Female" to indicate the person's gender.

CLIENT BIRTHDATE/AGE. Where the boxes specify, enter the numbers representing the person's birth date. Enter the month as a number from 01 to 12 for January through December. Enter the day as a two-digit number (01 to 31). Enter the last two digits of the birth year (for example, "70" for 1970). Make sure that if a month or day is less than 10, you place a "0" before the number. If the person does not want to tell you his/her birth date, leave these boxes blank. If you do not know the person’s birthdate, fill in his/her age in the boxes labeled "Month/Age" and leave the "Day" and "Year" boxes blank. Estimate the age if the person does not tell you him or herself. You must enter birthdate if you are using the TMG unique identifier.

SERVICE LOCATION. Darken the circle next to the place where the service was given. If it was not at one of the locations listed here, enter a brief description of the place in the boxes next to "Other." Darken only one circle to indicate the service location.

Street. Darken this circle if the service took place outside on the street or in a park.

CBO. Darken this circle if the service took place at a community based organization or agency.

Shelter/Drop-In. Darken this circle if the service took place at a shelter or drop-in facility.

Clinic. Darken this circle if the service took place at a clinic.

Hospital. Darken this circle if the service took place at a hospital.

Telephone. Darken this circle if the service took place over the telephone.

Home. Darken this circle if the service took place at the person’s home.

Job. Darken this circle if the service took place at the person’s job.

Restaurant. Darken this circle if the service took place at a restaurant (fast food or other).

 

Topics Discussed. For the items listed under "Topics Discussed," darken the circle next to all of the topics that were discussed with the person during the session. For example, if you discussed HIV Risk Factors with the person, you would darken the circle labeled "HIV Risk Factors." If you discussed a topic that is not listed here, write in a short description of the topic in the boxes labeled "Other."

HIV Risk Factors. Darken this circle if the topics discussed related to HIV risk factors, including but not limited to sexual behaviors, injection and other drug use, blood sharing, and other factors that increase a person's risk for HIV.

"Safer" Sex. Darken this circle if the topics discussed related to "safer sex" and ways to reduce risk through using latex protection and less risky sexual behaviors.

HIV Testing. Darken this circle if the topics discussed related to getting HIV testing, what the test means, pre- and post-test counseling, implications of getting tested, and other related topics.

HIV Services. Darken this circle if the topics discussed related to getting prevention, intervention, and/or treatment services for HIV for oneself or someone else.

Medical Services. Darken this circle if the topics discussed related to health and medical services in general, not necessarily specific to HIV or AIDS.

Public Assistance. Darken this circle if the topics discussed related to getting benefits the person may be eligible for, such as welfare, AFDC, food stamps, etc.

Alternate Therapies. Darken this circle if the topics discussed related to alternative therapies including herbals, acupuncture, Chinese medicine, etc.

Family Planning. Darken this circle if the topics discussed related to contraception/birth control advice and services, and related family planning issues.

Substance Abuse. Darken this circle if the topics discussed related to alcohol and other drug abuse, including but not limited to prevention, identification of abuse, intervention and treatment services, links between substance abuse and HIV, 12-step groups, and other related issues.

Emotional Problems. Darken this circle if you discussed mental or emotional problems.

"Hassles." Darken this circle if the topics discussed related to problems in general; not specifically identified in terms of the other categories listed. Includes relationship problems with family and peers.

Assertiveness. Darken this circle if the topics discussed related to assertiveness. May include learning to be more assertive.

Housing/Jobs. Darken this circle if the topics discussed related to obtaining housing or jobs. May include job skills, vocational training, etc.

Enrollment. Darken this circle if you discussed enrolling in your program with the individual.

Self Identity. Darken this circle if the topics discussed related to identity and sexual orientation.

Youth Empowerment. Darken this circle if the topics discussed related to teaching youth skills to negotiate the service system on their own. This is similar to advocacy, but in youth empowerment the youth learns how to advocate for him or herself.

Living with HIV. Darken this circle if the topics discussed related to living with HIV disease. Can refer to oneself or a family member or friend.

Health Status. Darken this circle if the topics discussed related to the respondent's health.

Dating/Sex. Darken this circle if the topics discussed related to dating, relationships, and sex.

Risk Reduction Barriers. Darken this circle if the topics discussed related to barriers to reducing one's risk of HIV. Includes reasons why it is hard for youth to change risky behaviors.

 

TYPE OF SESSION. For the items listed under "TYPE OF SESSION," darken the circle next to all of the items that describe the session. For example, if the person was given a medical physical examination and an HIV test, you would darken the circle labeled "Medical--physical exam" and the circle labeled "HIV Test." If services were given that are not listed here, write in a short description of the services in the boxes under "Other Services." Write the first service in the boxes labeled "#1" and if there was a second service given that is not listed here, write it in the boxes labeled "#2."

Medical--physical exam. Darken this circle if the person was given a physical exam, including exams for general health care or HIV-specific.

Medical--lab (not HIV). Darken this circle if the person had general lab work done (not specifically HIV-related).

Medical--emergency. Darken this circle if the person had a medical emergency, including visits to an emergency room or urgent care clinic.

Medical--appt. Darken this circle if the person had a scheduled medical appointment.

Medical--walk-in. Darken this circle if the person had an unscheduled medical visit to a clinic or medical office.

Family Planning. Darken this circle if the session included advice and services related to contraception/birth control, and related family planning issues.

Substance Abuse/Mental Health Screening. Darken this circle if the session included screening for substance abuse and/or mental health issues needing further attention.

HIV Risk Assessment. Darken this circle if the session included assessment of an individual's risk level for HIV infection.

HIV Test. Darken this circle if the person took an HIV test.

HIV Pre-Test Counseling. Darken this circle if the person received counseling prior to taking an HIV test.

HIV Post-Test Counseling. Darken this circle if the person received counseling after taking an HIV test; may or may not be when the person receives the test results.

HIV Prevention. Darken this circle if the session included activities designed to reduce the risk of HIV infection.

Other Prevention. Darken this circle if the session included activities designed to reduce the risk of other risky behaviors or to prevent related problems such as substance abuse, violence, other health problems, etc.

Individual Counseling/Therapy. Darken this circle if the session included individual (one-on-one) counseling or therapy from a psychologist, social worker, counselor, or other service provider.

Group Counseling/Therapy. Darken this circle if the session included group counseling or therapy from a psychologist, social worker, counselor, or other service provider.

Family/Couple Counsel/Therapy. Darken this circle if the session included counseling or therapy with family members or a partner, and services were provided by a psychologist, social worker, counselor, or other service provider.

Crisis Intervention. Darken this circle if the intervention was made for acute crisis; may be provided by a psychologist, social worker, counselor, or other service provider.

"Alternate" Therapy. Darken this circle if the session included alternative therapies such as herbals, acupuncture, Chinese medicine, etc.

Practical Support. Darken this circle if the person received help with daily life tasks like grocery shopping, meal preparation, running errands, etc.

12-Step Group. Darken this circle if the session included self-help groups concerned with issues related to addictions such as AA, CA, NA, GA, OA.

Peer Support Grp. Darken this circle if the session included self-help groups that are conducted by and for youth.

HIV Support Group. Darken this circle if the session included self-help groups concerned with issues related to HIV.

Info & Referral. Darken this circle if the session included providing information, education, and referrals for a variety of problems.

Recreation. Darken this circle if the session included recreational events like parties, field trips, social activities, etc.

 

Was the session primarily about....

Prevention. If the session was primarily about HIV prevention, darken the circle labeled "Yes." If it was mostly about some other topic, darken the circle labeled "No."

Treatment. If the session was primarily about HIV treatment, darken the circle labeled "Yes." If it was mostly about some other topic, darken the circle labeled "No."

 

ITEMS PROVIDED AT THE CONTACT. Darken the circle next to all of the items that were provided at the session. For example, if brochures and condoms were given to the person, you would darken the circle next to "Brochures" and the circle next to "Condoms." If you provided an item that is not listed here, write in a short description of the item in the boxes labeled "Other."

Brochures. Darken this circle if brochures, pamphlets, or flyers were provided. Any short printed material can be counted as a brochure.

Other Educational Materials. Darken this circle if other educational materials were provided (not brochures, service directories, or wallet cards).

Referral Lists/Directories. Darken this circle if you provided referral lists or service provider directories.

Wallet Cards. Darken this circle if you provided a wallet card or other small card with information about hotlines, service provider agencies and other programs.

Immunizations. Darken this circle if you provided immunizations for the participants.

Medications. Darken this circle if medications were prescribed or provided directly to participants.

Condoms. Darken this circle if you provided condoms.

Dental Dams. Darken this circle if you provided dental dams.

Bus Tokens/Transport. Darken this circle if you provided bus tokens, transportation or vouchers (such as taxi vouchers).

Food/Vouchers. Darken this circle if you provided food or food vouchers.

Bleach. Darken this circle if you provided bleach or bleach kits.

 

SERVICES PROVIDED BY. Darken the circle next to all of the people who provided services to this person during this session. For example, if a medical doctor examined or treated the person, you would darken the circle next to "Physician." If the service was provided by some other type of person, write a short description in the boxes indicated.

Physician. Darken this circle if the service was provided by a medical doctor. A physician's assistant (PA) should be marked under "Other."

Nurse. Darken this circle if the service was provided by a nurse (RN, LVN, etc.)

Psychiatrist. Darken this circle if the service was provided by a psychiatrist (a medical doctor specializing in psychiatry.)

Health Educator. Darken this circle if the service was provided by a staff member who provides information about health practices, nutrition, etc.

Case Manager. Darken this circle if the service was provided by a staff member who coordinates a number of services for a client. Case managers may also be social workers, but not necessarily.

Social Worker. Darken this circle if the service was provided by a social worker. Social workers provide mental health and social services. They usually have a Master's degree (MSW) and sometimes are licensed by the state (LSCW).

Psychologist. Darken this circle if the service was provided by a psychologist. Psychologists provide mental health and some other social services. They usually have a doctorate (PhD, EdD, or PsyD) but often may have a Master's degree (MA or MS).

Other MH Worker. This refers to some other type of mental health care worker, such as a Marriage, Family and Child Counselor (MFCC).

Public Health Worker. Darken this circle if the service was provided by a public health worker. Public health workers may include Public Health Nurses and other service providers who work in a public health setting or for a public health department.

Outreach Worker. Darken this circle if the service was provided by an outreach worker. Outreach workers go into the community to raise awareness of problems and services.

Counselor. Darken this circle if the service was provided by a counselor. Counselors can be professionals or paraprofessionals who provide individual or group counseling.

Peer Counselor. Darken this circle if the service was provided by a counselor who is approximately the same age as the client.

Teacher. Darken this circle if the service was provided by a school teacher.

 

REFERRALS MADE TO THESE SERVICES. For each of the services listed, write in an "I," an "O," or a "B" if you made a referral to that service. Enter an "I" if a referral was made to services within your agency ("I" stands for Inside). Enter an "O" if a referral was made to services outside your agency ("O" stands for Outside). Enter a "B" if a referral was made to services both inside and outside of your agency ("B" stands for Both). For example, if you referred the person to another agency for HIV testing you would enter an "O" in the box to the left of the label "HIV Testing."

HIV Testing. Enter an "I," an "O," or a "B" if you made a referral for HIV testing.

STD Clinic. Enter an "I," an "O," or a "B" if you made a referral to an STD clinic.

Medical Services. Enter an "I," an "O," or a "B" if you made a referral for medical services. This may include general health services as well as medical services that are specifically HIV-related.

Social Services. Enter an "I," an "O," or a "B" if you made a referral to a social service agency.

Food/Drop-In Center. Enter an "I," an "O," or a "B" if you made a referral to a drop-in shelter, food bank, or similar resource.

Shelter/Housing. Enter an "I," an "O," or a "B" if you made a referral to a shelter.

Educational/Voc. Training. Enter an "I," an "O," or a "B" if you made a referral to educational or vocational services.

Self-Help Group(s). Enter an "I," an "O," or a "B" if you made a referral to self-help groups (including 12-step and other support groups).

Case Manager. Enter an "I," an "O," or a "B" if you made a referral to a case manager.

Mental Health. Enter an "I," an "O," or a "B" if you made a referral for mental health services.

Substance Abuse. Enter an "I," an "O," or a "B" if you made a referral to a substance abuse program (inpatient or outpatient).

Family Planning. Enter an "I," an "O," or a "B" if you made a referral to a family planning clinic or other agency providing family planning services.

 

Was the session primarily CASE MANAGEMENT? Darken the circle next to "yes" or "no" to indicate if the session was mainly case management.

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