SPNS COOPERATIVE AGREEMENT EVALUATION

MODULE 19: HIV/AIDS HEALTH FORM-WOMEN INSTRUCTIONS

Citation: Huba, G. J., Melchior, L. A., Staff of The Measurement Group, and HRSA/HAB's SPNS Cooperative Agreement Steering Committee (1996). Module 19: HIV/AIDS Health Form - Women. 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 19: HIV/AIDS Health-Women 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. If it has not been already entered on the form, look up your code in the table below. 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.

Have you ever had any of the following? Ask the client questions 1 through 4. If the client responds yes, ask her if she had the condition in the past 6 months and indicate her response by darkening the appropriate circle in the middle column titled "If yes, in past 6 months?" If the client responds that she has had the condition in the past 6 months, ask her if she had it in the past 30 days and indicate her response by darkening the appropriate circle in the right column titled "If yes, in past 30 days?"

Bacterial vaginosis (BV), or gardnerella (vaginitis-imflammation of the vagina). If the client responds "No,", "Don’t Know,’ or refuses to answer darken the appropriate circle and go to question 2. If the client responds "Yes," ask her if she had bacterial vaginosis in the past 6 months and indicate her response by darkening the appropriate circle in the middle column titled "If yes, in past 6 months?" If the client has not had bacterial vaginosis in the past 6 months go to question 2. If the client responds that she has had bacterial vaginosis in the past 6 months, ask her if she had it in the past 30 days and indicate her response by darkening the appropriate circle in the right column titled "If yes, in past 30 days?" and go to question 2.

Trichomonas ("trich"; type of vaginal infection) If the client responds "No,", "Don’t Know,’ or refuses to answer darken the appropriate circle and go to question 3. If the client responds "Yes," ask her if she had trichomonas in the past 6 months and indicate her response by darkening the appropriate circle in the middle column titled "If yes, in past 6 months?" If the client has not had trichomonas in the past 6 months go to question 3. If the client responds that she has had trichomonas in the past 6 months, ask her if she had it in the past 30 days and indicate her response by darkening the appropriate circle in the right column titled "If yes, in past 30 days?" and go to question 3.

PID (pelvic inflammatory disease; infection of the internal female reproductive organs) If the client responds "No,", "Don’t Know,’ or refuses to answer darken the appropriate circle and go to question 3. If the client responds "Yes," ask her if she had PID in the past 6 months and indicate her response by darkening the appropriate circle in the middle column titled "If yes, in past 6 months?" If the client has not had PID in the past 6 months go to question 4. If the client responds that she has had PID in the past 6 months, ask her if she had it in the past 30 days and indicate her response by darkening the appropriate circle in the right column titled "If yes, in past 30 days?" and go to question 4.

Abnormal pap smear (abnormal results from a cervical smear test) If the client responds "No,", "Don’t Know,’ or refuses to answer darken the appropriate circle and go to question 3. If the client responds "Yes," ask her if she had an abnormal pap smear in the past 6 months and indicate her response by darkening the appropriate circle in the middle column titled "If yes, in past 6 months?" If the client has not had an abnormal pap smear in the past 6 months go to question 5. If the client responds that she has had an abnormal pap smear in the past 6 months, ask her if she had it in the past 30 days and indicate her response by darkening the appropriate circle in the right column titled "If yes, in past 30 days?" and go to question 5.

Have you ever been pregnant? (one only) If the client responds "Yes," darken the circle next to "Yes," and go on to ask questions 5a through 5f. If the client responds that she has never been pregnant, darken the circle next to "No" and end the interview. Also, darken the appropriate circle and end the interview if the client responds "Don’t Know" or refuses to answer the question.

How many time have you ever been pregnant? In the boxes provided, enter the number of times the client has been pregnant. Right justify the number by placing "0s" to the left of it. For example, if the client has been pregnant 3 times, enter "003." If the client does not know how many times she has been pregnant, enter "777." If she refuses to tell you how many times she has been pregnant, enter "888."

Are you currently pregnant? (one only) If the client is currently pregnant, darken the circle next to "Yes." If the client is not currently pregnant, darken the circle next to "no." If she does not know, darken the circle next to "Don’t Know." If she refuses to answer, darken the circle next to "Refused."

How old were you the first time you became pregnant? Enter the age of the client at the first time she became pregnant. Enter "77" if she does not know. Enter "88" if she refuses to answer.

How many children have you given birth to?

Have you ever had an abortion? (one only) If the client has had an abortion, darken the circle next to "Yes." If the client is not currently pregnant, darken the circle next to "no." If she does not know, darken the circle next to "Don’t Know." If she refuses to answer, darken the circle next to "Refused."

How many abortions have you ever had? Enter the number of abortions the client has had as a two digit number. For example if the client has had 3 abortions, enter "03" in the boxes provided. Enter "77" if she does not know. Enter "88" if she refuses to answer.

Have you ever had a miscarriage? (one only) If the client has had a miscarriage, darken the circle next to "Yes." If the client has not had a miscarriage, darken the circle next to "no." If she does not know, darken the circle next to "Don’t Know." If she refuses to answer, darken the circle next to "Refused."

How many miscarriages have you ever had? Enter the number of miscarriages the client has had as a two digit number. For example if the client has had 3 miscarriages, enter "03" in the boxes provided. Enter "77" if she does not know. Enter "88" if she refuses to answer.