Module 72: Missed Visit / Appointment Form

A Module Used in The Measurement Group's Cross-Cutting Evaluation of the HRSA HIV/AIDS Bureau's Special Projects of National Significance on Innovative Models of HIV/AIDS Care

Purpose

• The purpose of this module is to record missed appointments or office visits by a client. This is a key issue in tracking adherence to program advice.

Content Domain - Codes type of appointment missed and reason missed.

Operational Data Items - ID Letters/ID Numbers, Site, Sub-Provider, Date of Visit/Appointment, Staff Code, Type of Visit, Location of Visit, Reason for Missed Visit/Appointment, Has Client Missed Two Consecutive Visits, Action(s) Taken by Client, Action(s) Taken or Attempts Made to Encourage Client to Keep Appointment(s), Date Provider Last Attempted to Reach Client, Number of Attempts Made.

Citation - Huba, G. J., Melchior, L. A., Staff of The Measurement Group, and HRSA/HAB's SPNS Cooperative Agreement Steering Committee (1996). Module 72: Missed Visit/Appointment Form. Available: www.TheMeasurementGroup.com. Culver City, California: The Measurement Group.

Usage - Permission is granted for non-commercial use so long as form is not altered, the copyright is not removed, and a proper citation is made to the instrument. Non-commercial use is use by a not-for-profit organization in which the instrument is not sold. If you have questions about appropriate and proper uses, contact The Measurement Group.

Findings from Evaluating HIV/AIDS Programs

Reliability and Validity Studies