Module 74: Urinalysis Report 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 form is to record the results of urinalysis that may be conducted as part of monitoring for use of alcohol or other drugs.

Content Domain - Codes substances detected and confirmed via urinalysis. Does not specify which assay method is used in the urinalysis.

Operational Data Items - ID Letters/ID Numbers, Site, Sub-Provider, Date Form Completed, Staff Code, Date of Urinalysis, Drugs Detected and Confirmed (with option for Negative for All Drugs).

Citation - Huba, G. J., Melchior, L. A., Staff of The Measurement Group, and HRSA/HAB's SPNS Cooperative Agreement Steering Committee (1995). Module 74: Urinalysis Report 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