SPNS COOPERATIVE AGREEMENT EVALUATION

MODULE 10: HIV TESTING HISTORY FORM INSTRUCTIONS

Citation: Huba, G. J., Melchior, L. A., Staff of The Measurement Group, and HRSA/HAB's SPNS Cooperative Agreement Steering Committee (1996). Module 10: HIV Testing History Form. Available: www.TheMeasurementGroup.com. Culver City, California: The Measurement Group.

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. 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. Only darken one circle for each question unless the instructions specifically tell you to darken as many as apply for that question.

Specific Parts of the Module 10: HIV Testing History Form

ID Letters/ID Numbers. These boxes are provided for entering the unique identifier your site is using to track client information. The four boxes on the left are to be used for letters, while the ten boxes on the right are reserved for numbers. You may use letters, numbers, or a combination of letters and numbers, for identification purposes. If you use a combination of letters and numbers, however, please use the letters first in your alphanumeric sequence (for example, if your unique identifier is MD-1479, the letters "M" and "D" would be entered in the first two of the four boxes reserved for letters and the numbers "1", "4", "7", and "9" would be entered into the first four of the ten boxes reserved for numbers). If you are unsure about a client’s unique identifier, check with your project director.

Site. This is a code to identify your project in the cross-cutting evaluation. It should be pre-printed on the form. Site codes are 3 letters.

Sub-Provider. This field may be used to designate specific sites or providers within your project. If appropriate, enter the code for the service provider agency doing the activity. Provider codes can be up to 3 letters.

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, "95" for 1995). Make sure that if a month or day is less than 10, you place a "0" before the number.

Staff Code. Each staff member should be assigned a unique number code (up to 3 digits). Make sure than each new staff member has a unique code. Do not reassign any staff codes that have been previously assigned. Enter the 3-digit code for the person who provided the services. If the staff code is less than 3 digits, place "0"s before the number. For example, 3 is "003."

Client Gender. Darken the circle next to the response that indicates the person's gender.

This module is designed as a structured interview form. For each section, follow the instructions and arrows to ask the questions in the order indicated. You may skip over some questions if the respondent answers in certain ways that warrant a skip, as indicated on the form. It is important to ask probing questions if the client appears uncertain or hesitant about a response, as these questions concern private matters that may be difficult to discuss. Probes may lead to a more accurate response than the initial response.

Part 1: Have You Been Tested for HIV?

Ever? Darken the circle next to "No" if the person has never been tested for HIV. Darken the circle next to "D/K" if the person does not know. Darken the circle next to "Ref." if the person refuses to answer. Darken the circle next to "Yes" if the person has been tested for HIV. If the person answers "No" or "D/K" or "Ref," skip to Part 3.

Year This Happened for The First Time. Fill in the boxes with the year in which the person was tested for HIV for the first time. Enter the last two digits of the year (for example, "96" for 1996).

In the Last Six Months? Darken the circle next to "No" if the person has not been tested for HIV in the last six months. Darken the circle next to "D/K" if the person does not know. Darken the circle next to "Ref." if the person refuses to answer. Darken the circle next to "Yes" if the person has been tested for HIV in the last six months.

In the Last 30 Days? Darken the circle next to "No" if the person has not been tested for HIV in the last 30 days. Darken the circle next to "D/K" if the person does not know. Darken the circle next to "Ref." if the person refuses to answer. Darken the circle next to "Yes" if the person has been tested for HIV in the last 30 days.

How many times have you been tested for HIV? Fill in the boxes with the number of times the person has been tested for HIV. If the number is less than 100, place "0"s to the left of the number (e.g., 11 times = "011"). If the client has been tested 1 time, ask questions 1 to 6, then skip to Part 2. If the clients has been tested more than 1 time, ask questions 1 to 12.

FIRST HIV TEST: Questions 1 to 6 pertain to the first time the client was tested for HIV.

The first time you were tested for HIV, did you understand what was happening? Referring to the first time the person was tested for HIV, darken the circle next to "No" if the person said he/she did not understand what was happening. Darken the circle next to "Yes" if the person said he/she understood what was happening. Darken the circle next to "D/K" if the person does not know. Darken the circle next to "Ref." if the person refuses to answer.

Did you get counseling before your first HIV test? Darken the circle next to "No" if the person did not get counseling before his/her first HIV test. Darken the circle next to "Yes" if the person got counseling before his/her first HIV test. Darken the circle next to "D/K" if the person does not know. Darken the circle next to "Ref." if the person refuses to answer.

Did you get counseling after your first HIV test? Darken the circle next to "No" if the person did not get counseling after his/her first HIV test. Darken the circle next to "Yes" if the person got counseling after his/her first HIV test. Darken the circle next to "D/K" if the person does not know. Darken the circle next to "Ref." if the person refuses to answer.

Were you in jail when you had your first HIV test? Darken the circle next to "No" if the person was not in jail when he/she had his/her first HIV test. Darken the circle next to "Yes" if the person was in jail when he/she had his/her first HIV test. Darken the circle next to "D/K" if the person does not know. Darken the circle next to "Ref." if the person refuses to answer.

Did you have a choice about getting your first HIV test? Darken the circle next to "No" if the person did not have a choice about getting his/her first HIV test. Darken the circle next to "Yes" if the person did have a choice about getting his/her first HIV test. Darken the circle next to "D/K" if the person does not know. Darken the circle next to "Ref." if the person refuses to answer.

Was your first HIV test given when you had a baby? Darken the circle next to "No" if the first time the person was tested was not when she had a baby. Darken the circle next to "Yes" if the first time the person was tested was when she had a baby. Darken the circle next to "D/K" if the person does not know. Darken the circle next to "Ref." if the person refuses to answer. Darken the circle next to "N/A" if the person does not have any children or is male.

MOST RECENT HIV TEST: Questions 7 to 12 pertain to the most recent time the client was tested for HIV. If he or she has only been tested once, skip to Part 2 (but ask questions 1 to 6 in this section about the first time they were tested).

The most recent time you were tested for HIV, did you understand what was happening? Referring to the most recent time the person was tested for HIV, darken the circle next to "No" if the person said he/she did not understand what was happening. Darken the circle next to "Yes" if the person said he/she understood what was happening. Darken the circle next to "D/K" if the person does not know. Darken the circle next to "Ref." if the person refuses to answer.

Did you get counseling before your most recent HIV test? Darken the circle next to "No" if the person did not get counseling before his/her most recent HIV test. Darken the circle next to "Yes" if the person got counseling before his/her most recent HIV test. Darken the circle next to "D/K" if the person does not know. Darken the circle next to "Ref." if the person refuses to answer.

Did you get counseling after your most recent HIV test? Darken the circle next to "No" if the person did not get counseling after his/her most recent HIV test. Darken the circle next to "Yes" if the person got counseling after his/her most recent HIV test. Darken the circle next to "D/K" if the person does not know. Darken the circle next to "Ref." if the person refuses to answer.

Were you in jail when you had your most recent HIV test? Darken the circle next to "No" if the person was not in jail when he/she had his/her most recent HIV test. Darken the circle next to "Yes" if the person was in jail when he/she had his/her most recent HIV test. Darken the circle next to "D/K" if the person does not know. Darken the circle next to "Ref." if the person refuses to answer.

Did you have a choice about getting your most recent HIV test? Darken the circle next to "No" if the person did not have a choice about getting his/her most recent HIV test. Darken the circle next to "Yes" if the person did have a choice about getting his/her most recent HIV test. Darken the circle next to "D/K" if the person does not know. Darken the circle next to "Ref." if the person refuses to answer.

Was your most recent HIV test given when you had a baby? Darken the circle next to "No" if the most recent HIV test was not when she had a baby. Darken the circle next to "Yes" if the most recent time the person was tested was when she had a baby. Darken the circle next to "D/K" if the person does not know. Darken the circle next to "Ref." if the person refuses to answer. Darken the circle next to "N/A" if the person does not have any children or is male.

Part 2: Have You Had A Positive Test for HIV?

Ever? Darken the circle next to "No" if the person has never had a positive test for HIV. Darken the circle next to "D/K" if the person does not know. Darken the circle next to "Ref." if the person refuses to answer. Darken the circle next to "Yes" if the person has tested positive for HIV. If the person answers "No" or "D/K" or "Ref," skip to Part 3.

Year This Happened for The First Time. Fill in the boxes with the year in which the person tested positive for HIV for the first time. Enter the last two digits of the year (for example, "96" for 1996).

In the Last Six Months? Darken the circle next to "No" if the person has not had a positive test for HIV in the last six months. Darken the circle next to "D/K" if the person does not know. Darken the circle next to "Ref." if the person refuses to answer. Darken the circle next to "Yes" if the person has had a positive test for HIV in the last six months.

In the Last 30 Days? Darken the circle next to "No" if the person has not had a positive test for HIV in the last 30 days. Darken the circle next to "D/K" if the person does not know. Darken the circle next to "Ref." if the person refuses to answer. Darken the circle next to "Yes" if the person has had a positive test for HIV in the last 30 days.

How many times have you tested positive for HIV? Fill in the boxes with the number of times the person has tested positive for HIV. If the number is less than 100, place "0"s to the left of the number (e.g., 9 times = "009"). If the person tested positive only one time, ask questions 1 through 3 (shaded) and then skip to Part 3. If the person tested positive more than one time. ask questions 1 through 6.

After you tested positive for HIV the first time, did someone help you get services? Referring to after the person tested positive for HIV for the first time, darken the circle next to "No" if the person has did not have someone help him/her get services. Darken the circle next to "Yes" if the person did have someone help him/her get services. Darken the circle next to "D/K" if the person does not know. Darken the circle next to "Ref." if the person refuses to answer. If the person answers "No" or "D/K" or "Ref," skip to Questions 2 and 3 (shaded) in this section.

Was the person(s) who helped, a... ? (Bubble in all that apply.) Referring to after the person tested positive for HIV the first time, darken the circle next to "doctor" if the person who helped him/her was a doctor. Darken the circle next to "nurse" if the person who helped him/her was a nurse. Darken the circle next to "social worker" if the person who helped him/her was a social worker. Darken the circle next to "drug counselor" if the person who helped him/her was a drug counselor. Darken the circle next to "other" if the person who helped him/her is not listed here. Darken the circle next to "no one helped" if no one helped him/her.

Did this person(s) say you should get:

Medical services? Referring to after the client tested positive for HIV the first time, darken the circle next to "No" if none of the people who helped the client said he/she should get medical services. Darken the circle next to "Yes" if any of the people who helped said he/she should get medical services. Darken the circle next to "D/K" if the person does not know. Darken the circle next to "Ref." if the person refuses to answer.

Drug treatment? Referring to after the client tested positive for HIV the first time, darken the circle next to "No" if none of the people who helped the client said he/she should get drug treatment. Darken the circle next to "Yes" if any of the people who helped said he/she should get drug treatment. Darken the circle next to "D/K" if the person does not know. Darken the circle next to "Ref." if the person refuses to answer.

Counseling? Referring to after the client tested positive for HIV the first time, darken the circle next to "No" if none of the people who helped the client said he/she should get counseling. Darken the circle next to "Yes" if any of the people who helped said he/she should get counseling. Darken the circle next to "D/K" if the person does not know. Darken the circle next to "Ref." if the person refuses to answer.

Help with food, shelter, job training? Referring to after the client tested positive for HIV the first time, darken the circle next to "No" if none of the people who helped the client said he/she should get food, shelter, or job training. Darken the circle next to "Yes" if any of the people who helped said he/she should get food, shelter, or job training. Darken the circle next to "D/K" if the person does not know. Darken the circle next to "Ref." if the person refuses to answer.

Did you try to get:

Medical services? Referring to after the person tested positive for HIV the first time, darken the circle next to "No" if the person did not try to get medical services. Darken the circle next to "Yes" if the person did try to get medical services. Darken the circle next to "D/K" if the person does not know. Darken the circle next to "Ref." if the person refuses to answer.

Drug treatment? Referring to after the person tested positive for HIV the first time, darken the circle next to "No" if the person did not try to get drug treatment. Darken the circle next to "Yes" if the person did try to get drug treatment. Darken the circle next to "D/K" if the person does not know. Darken the circle next to "Ref." if the person refuses to answer.

Counseling? Referring to after the person tested positive for HIV the first time, darken the circle next to "No" if the person did not try to get counseling. Darken the circle next to "Yes" if the person did try to get counseling. Darken the circle next to "D/K" if the person does not know. Darken the circle next to "Ref." if the person refuses to answer.

Help with food, shelter, job training? Referring to after the person tested positive for HIV the first time, darken the circle next to "No" if the person did not try to get help with food, shelter, job training. Darken the circle next to "Yes" if the person did try to get help with food, shelter, job training. Darken the circle next to "D/K" if the person does not know. Darken the circle next to "Ref." if the person refuses to answer.

Did you get them:

Medical services? Referring to after the person tested positive for HIV the first time, darken the circle next to "No" if the person did not get medical services. Darken the circle next to "Yes" if the person did get medical services. Darken the circle next to "D/K" if the person does not know. Darken the circle next to "Ref." if the person refuses to answer.

Drug treatment? Referring to after the person tested positive for HIV the first time, darken the circle next to "No" if the person did not get drug treatment. Darken the circle next to "Yes" if the person did get drug treatment. Darken the circle next to "D/K" if the person does not know. Darken the circle next to "Ref." if the person refuses to answer.

Counseling? Referring to after the person tested positive for HIV the first time, darken the circle next to "No" if the person did not get counseling. Darken the circle next to "Yes" if the person did get counseling. Darken the circle next to "D/K" if the person does not know. Darken the circle next to "Ref." if the person refuses to answer.

Help with food, shelter, job training? Referring to after the person tested positive for HIV the first time, darken the circle next to "No" if the person did not get help with food, shelter, job training. Darken the circle next to "Yes" if the person did get help with food, shelter, job training. Darken the circle next to "D/K" if the person does not know. Darken the circle next to "Ref." if the person refuses to answer.

After you tested positive for HIV the most recent time, did someone help you get services? Referring to after the person tested positive for HIV the most recent time, darken the circle next to "No" if someone did not get help him/her get services. Darken the circle next to "Yes" if someone did not get help him/her get services. Darken the circle next to "D/K" if the person does not know. Darken the circle next to "Ref." if the person refuses to answer. If the person answers "No" or "D/K" or "Ref," skip to Part 3.

Was the person(s) who helped, a... ? (Bubble in all that apply.) Referring to after the person tested positive for HIV the most recent time, darken the circle next to "doctor" if the person who helped him/her was a doctor. Darken the circle next to "nurse" if the person who helped him/her was a nurse. Darken the circle next to "social worker" if the person who helped him/her was a social worker. Darken the circle next to "drug counselor" if the person who helped him/her was a drug counselor. Darken the circle next to "other" if the person who helped him/her is not listed here. Darken the circle next to "no one helped" if no one helped him/her.

Did this person(s) say you should get:

Medical services? Referring to after the client tested positive for HIV the most recent time, darken the circle next to "No" if none of the people who helped the client said he/she should get medical services. Darken the circle next to "Yes" if any of the people who helped said he/she should get medical services. Darken the circle next to "D/K" if the person does not know. Darken the circle next to "Ref." if the person refuses to answer.

Drug treatment? Referring to after the client tested positive for HIV the most recent time, darken the circle next to "No" if none of the people who helped the client said he/she should get drug treatment. Darken the circle next to "Yes" if any of the people who helped said he/she should get drug treatment. Darken the circle next to "D/K" if the person does not know. Darken the circle next to "Ref." if the person refuses to answer.

Counseling? Referring to after the client tested positive for HIV the most recent time, darken the circle next to "No" if none of the people who helped the client said he/she should get food, shelter, or job training. Darken the circle next to "Yes" if any of the people who helped said he/she should get food, shelter, or job training. Darken the circle next to "D/K" if the person does not know. Darken the circle next to "Ref." if the person refuses to answer.

Help with food, shelter, job training? Referring to after the client tested positive for HIV the most recent time, darken the circle next to "No" if none of the people who helped the client said he/she should get food, shelter, or job training. Darken the circle next to "Yes" if any of the people who helped said he/she should get food, shelter, or job training. Darken the circle next to "D/K" if the person does not know. Darken the circle next to "Ref." if the person refuses to answer.

Did you try to get:

Medical services? Referring to after the person tested positive for HIV the most recent time, darken the circle next to "No" if the person did not try to get medical services. Darken the circle next to "Yes" if the person did try to get medical services. Darken the circle next to "D/K" if the person does not know. Darken the circle next to "Ref." if the person refuses to answer.

Drug treatment? Referring to after the person tested positive for HIV the most recent time, darken the circle next to "No" if the person did not try to get drug treatment. Darken the circle next to "Yes" if the person did try to get drug treatment. Darken the circle next to "D/K" if the person does not know. Darken the circle next to "Ref." if the person refuses to answer.

Counseling? Referring to after the person tested positive for HIV the most recent time, darken the circle next to "No" if the person did not try to get counseling. Darken the circle next to "Yes" if the person did try to get counseling. Darken the circle next to "D/K" if the person does not know. Darken the circle next to "Ref." if the person refuses to answer.

Help with food, shelter, job training? Referring to after the person tested positive for HIV the most recent time, darken the circle next to "No" if the person did not try to get help with food, shelter, job training. Darken the circle next to "Yes" if the person did try to get help with food, shelter, job training. Darken the circle next to "D/K" if the person does not know. Darken the circle next to "Ref." if the person refuses to answer.

Did you get them?:

Medical services? Referring to after the person tested positive for HIV the most recent time, darken the circle next to "No" if the person did not get medical services. Darken the circle next to "Yes" if the person did get medical services. Darken the circle next to "D/K" if the person does not know. Darken the circle next to "Ref." if the person refuses to answer.

Drug treatment? Referring to after the person tested positive for HIV the most recent time, darken the circle next to "No" if the person did not get drug treatment. Darken the circle next to "Yes" if the person did get drug treatment. Darken the circle next to "D/K" if the person does not know. Darken the circle next to "Ref." if the person refuses to answer.

Counseling? Referring to after the person tested positive for HIV the most recent time, darken the circle next to "No" if the person did not get counseling. Darken the circle next to "Yes" if the person did get counseling. Darken the circle next to "D/K" if the person does not know. Darken the circle next to "Ref." if the person refuses to answer.

Food, shelter, job training? Referring to after the person tested positive for HIV the most recent time, darken the circle next to "No" if the person did not get help with food, shelter, job training. Darken the circle next to "Yes" if the person did get help with food, shelter, job training. Darken the circle next to "D/K" if the person does not know. Darken the circle next to "Ref." if the person refuses to answer.

Part 3: Do You Think You Have HIV or AIDS?

Do You Think You Have HIV or AIDS? Darken the circle next to "No" if the person does not think that he/she has HIV or AIDS. Darken the circle next to "D/K" if the person does not know. Darken the circle next to "Ref." if the person refuses to answer. Darken the circle next to "Yes" if the person thinks that he/she has HIV or AIDS.

Have you been told by a doctor or nurse that you had symptoms of HIV disease or AIDS Ever? Darken the circle next to "No" if the person has never been told that he/she has symptoms of HIV disease or AIDS. Darken the circle next to "D/K" if the person does not know if he/she has been told he/she has symptoms of HIV disease or AIDS. Darken the circle next to "Ref." if the person refuses to answer. Darken the circle next to "Yes" if the person has been told that he/she has symptoms of HIV disease or AIDS. If the person answers "No" or "D/K" or "Ref," stop here.

Year This Happened for The First Time. Fill in the boxes with the year in which the person was told for the first time by a doctor or nurse that he/she had symptoms of HIV disease or AIDS. Enter the last two digits of the year (for example, "95" for 1995).

In the Last Six Months? Darken the circle next to "No" if the person has not been told in the last six months by a doctor or nurse that he/she had symptoms of HIV disease or AIDS. Darken the circle next to "D/K" if the person does not know. Darken the circle next to "Ref." if the person refuses to answer. Darken the circle next to "Yes" if the person has been told in the last six months by a doctor or nurse that he/she had symptoms of HIV disease or AIDS.

In the Last 30 Days? Darken the circle next to "No" if the person has not been told in the last 30 days by a doctor or nurse that he/she had symptoms of HIV disease or AIDS. Darken the circle next to "D/K" if the person does not know. Darken the circle next to "Ref." if the person refuses to answer. Darken the circle next to "Yes" if the person has been told in the last 30 days by a doctor or nurse that he/she had symptoms of HIV disease or AIDS.

How many different times have you been told you had symptoms of HIV disease or AIDS? Fill in the boxes with the number of times the person has been told he/she has symptoms of HIV disease or AIDS. If the number is less than 100, place "0"s to the left of the number (e.g., 50 times = "050").

Who told you the first time you had symptoms of HIV disease or AIDS (all that apply)? Darken the circle next to "doctor" if the person who told the client was a doctor. Darken the circle next to "nurse" if the person who told him/her was a nurse. Darken the circle next to "social worker" if the person who told him/her was a social worker. Darken the circle next to "drug counselor" if the person who told him/her was a drug counselor. Darken the circle next to "other" if the person who told him/her is not listed here.

Did this person(s) say you should get:

Medical services? Referring to after the person was told he/she has symptoms of HIV disease or AIDS, darken the circle next to "No" if none of the people who told the client said he/she should get medical services. Darken the circle next to "Yes" if any of the people who told the client said he/she should get medical services. Darken the circle next to "D/K" if the person does not know. Darken the circle next to "Ref." if the person refuses to answer.

Drug treatment? Referring to after the person was told he/she has symptoms of HIV disease or AIDS, darken the circle next to "No" if none of the people who told the client said he/she should get drug treatment. Darken the circle next to "Yes" if any of the people who told the client said he/she should get drug treatment. Darken the circle next to "D/K" if the person does not know. Darken the circle next to "Ref." if the person refuses to answer.

Counseling? Referring to after the person was told he/she has symptoms of HIV disease or AIDS, darken the circle next to "No" if none of the people who told the client said he/she should get food, shelter, or job training. Darken the circle next to "Yes" if any of the people who told the client said he/she should get food, shelter, or job training. Darken the circle next to "D/K" if the person does not know. Darken the circle next to "Ref." if the person refuses to answer.

Help with food, shelter, job training? Referring to after the person was told he/she has symptoms of HIV disease or AIDS, darken the circle next to "No" if none of the people who told the client said he/she should get food, shelter, or job training. Darken the circle next to "Yes" if any of the people who told the client said he/she should get food, shelter, or job training. Darken the circle next to "D/K" if the person does not know. Darken the circle next to "Ref." if the person refuses to answer.

Did you try to get:

Medical services? Referring to after the person was told he/she has symptoms of HIV disease or AIDS, darken the circle next to "No" if the person who helped the client did not say he/she should get medical services. Darken the circle next to "Yes" if the person who helped did say he/she should get medical services. Darken the circle next to "D/K" if the person does not know. Darken the circle next to "Ref." if the person refuses to answer.

Drug treatment? Referring to after the person was told he/she has symptoms of HIV disease or AIDS, darken the circle next to "No" if the person did not try to get drug treatment. Darken the circle next to "Yes" if the person did try to get drug treatment. Darken the circle next to "D/K" if the person does not know. Darken the circle next to "Ref." if the person refuses to answer.

Counseling? Referring to after the person was told he/she has symptoms of HIV disease or AIDS, darken the circle next to "No" if the person did not try to get counseling. Darken the circle next to "Yes" if the person did try to get counseling. Darken the circle next to "D/K" if the person does not know. Darken the circle next to "Ref." if the person refuses to answer.

Food, shelter, job training? Referring to after the person was told he/she has symptoms of HIV disease or AIDS, darken the circle next to "No" if the person did not try to get help with food, shelter, job training. Darken the circle next to "Yes" if the person did try to get help with food, shelter, job training. Darken the circle next to "D/K" if the person does not know. Darken the circle next to "Ref." if the person refuses to answer.

Did you get them?:

Medical services? Referring to after the person was told he/she has symptoms of HIV disease or AIDS, darken the circle next to "No" if the person did not get medical services. Darken the circle next to "Yes" if the person did get medical services. Darken the circle next to "D/K" if the person does not know. Darken the circle next to "Ref." if the person refuses to answer.

Drug treatment? Referring to after the person was told he/she has symptoms of HIV disease or AIDS, darken the circle next to "No" if the person did not get drug treatment. Darken the circle next to "Yes" if the person did get drug treatment. Darken the circle next to "D/K" if the person does not know. Darken the circle next to "Ref." if the person refuses to answer.

Counseling? Referring to after the person was told he/she has symptoms of HIV disease or AIDS darken the circle next to "No" if the person did not get counseling. Darken the circle next to "Yes" if the person did get counseling. Darken the circle next to "D/K" if the person does not know. Darken the circle next to "Ref." if the person refuses to answer.

Help with food, shelter, job training? Referring to after the person was told he/she has symptoms of HIV disease or AIDS, darken the circle next to "No" if the person did not get help with food, shelter, job training. Darken the circle next to "Yes" if the person did get help with food, shelter, job training. Darken the circle next to "D/K" if the person does not know. Darken the circle next to "Ref." if the person refuses to answer.