1. CTS HIV Test Request Forms Training

2. Overview Introduction Introduction Explore new form Explore new form Practice Practice

3. Introduction New CDC requirements – standard set of data from public testing sites New CDC requirements – standard set of data from public testing sites PEMS (Program Evaluation and Monitoring System) PEMS (Program Evaluation and Monitoring System) Implementation: May 1, 2009 Implementation: May 1, 2009

4. Form Orientation Page 1: Patient, specimen, requested testing and risk information Page 1: Patient, specimen, requested testing and risk information Page 1: Sent to OSPHL Page 1: Sent to OSPHL Page 2: Carbon copy of page 1 for chart/folder Page 2: Carbon copy of page 1 for chart/folder Page 2: Detailed instructions on back Page 2: Detailed instructions on back Page 3: Post-test disposition Page 3: Post-test disposition Page 3: Detailed instructions on back Page 3: Detailed instructions on back

5. What’s New Test History section Test History section Reworded Risk Reduction and Referrals section Reworded Risk Reduction and Referrals section Reworded Risk and Exposures section Reworded Risk and Exposures section

6. Mailing Address & Test Form ID Mailing address: Send forms and specimens to the address listed Test Form ID: Ten digits; no dashes. Same number that is on labels Reference the test form ID on specimens and corresponding forms, if necessary

7. Patient Information Must be completed in its entirety! Patient ID/Chart Number is for use with your records – you should also complete this box if you have to assign the client a unique identifier other than DOB. Incomplete patient information will delay the processing of the test. 1/15/1975 MultnomahOR97232 341/15/2010 x

8. Submitter Information Section Site ID (4 or 5 digit) and submitter code (6 digits) is mandatory! Missing info will delay the processing of your test. Site ID (4 or 5 digit) and submitter code (6 digits) is mandatory! Missing info will delay the processing of your test. Sites have the option of leaving the rest of this section blank if registered with OSPHD HIV Prevention Program Sites have the option of leaving the rest of this section blank if registered with OSPHD HIV Prevention Program 0000001111

9. Non-Rapid Specimen Information Fill out this section for non-rapid testing Identify the specimen source being submitted Specimens that fall into the “other” category – check with lab to make sure they can process x

10. Non-Rapid Tests Requested Indicate if the test is confidential or anonymous. If confidential, write patient information on bottom section of carbon copy. Indicate Non-Rapid Test Requested: Screen (EIA and western blot if needed). Western Blot only (likely to be requested rarely, but may be used to confirm a previous result or conduct follow-up testing of a previously indeterminate test). x x Common Error Alert: Remember to check either confidential or anonymous!

11. Non-Rapid Tests Requested Confirmation of preliminary positive (EIA and western blot regardless of EIA result). If the rapid testing was done at a separate encounter, if possible, indicate the form ID for that rapid test by indicating the previous test form ID on the line next to this selection. If the rapid test was done the same encounter or if previous test form ID is not known, leave the line blank. Follow-up of invalid rapid test (EIA and western blot if needed). If other is selected indicate preferred test. Confirm with lab prior to ordering. 090200000 x x

12. Test History Ask client and indicate whether or not a previous HIV test was conducted and the result of that test if known Indicate month (mm) and year (yyyy) of known previous test. If month unknown, enter year and leave month blank. If year unknown, ask client to estimate the year Common Error Alert: Remember to record responses for “Previous HIV Testing”, if client answers “Yes” record appropriate response for “last test was”. In addition, if client answers yes, attempt to record previous testing date. xx x

13. Rapid Testing Complete this section only if HIV Rapid Test is performed at today’s encounter Complete this section only if HIV Rapid Test is performed at today’s encounter Indicate if the test is confidential or anonymous. Indicate if the test is confidential or anonymous. If no blood or oral specimen will be sent with test form to the laboratory (i.e. rapid test is negative) select ‘DATA ONLY FORM’ If no blood or oral specimen will be sent with test form to the laboratory (i.e. rapid test is negative) select ‘DATA ONLY FORM’ Common Error Alert: Remember to check either confidential or anonymous! Common Error Alert: Remember to complete ALL sections! x xxx x

14. Client Race & Ethnicity Ask client to identify their race and ethnicity. Ask client to identify their race and ethnicity. x x Common Error Alert: remember to check client identified race/ethnicity OR “don’t know” or “declined to answer”.

15. Reason for Test xx NEW!

16. Risk Reduction & Referrals Indicate whether you discussed risk reduction strategies with the client and if not, why Indicate whether you discussed risk reduction strategies with the client and if not, why Notice N/A options Notice N/A options Indicate whether HIV positive or negative high-risk client was referred to HIV Prevention Services: Indicate whether HIV positive or negative high-risk client was referred to HIV Prevention Services: Substance abuse treatment Substance abuse treatment Counseling Counseling HCV Testing HCV Testing Or any other explicit referral aimed at risk reduction Or any other explicit referral aimed at risk reduction Notice N/A options Notice N/A options x x Common Error Alert: remember to complete this section in its entirety!

17. Risk/Exposures Do not read this section as a checklist. Do not read this section as a checklist. Report affirmative answers, if and only if, the client is confident of the response Report affirmative answers, if and only if, the client is confident of the response x xx x x

18. Common Errors: Omitting the frequency for use of condoms/sharing of syringes and injection equipment. Omitting the frequency for use of condoms/sharing of syringes and injection equipment. x x Leaving the Risk and Exposures Section blank. If you are leaving this section blank, be sure to mark off one of the following options:

19. Labels Each form will have 10 labels Each form will have 10 labels 8 with just the form ID 8 with just the form ID 2 with both the form ID and an extra line for the 2 nd identifier 2 with both the form ID and an extra line for the 2 nd identifier Use one of the labels with extra line, write the 2 nd identifier & place on the specimen prior to submitting Use one of the labels with extra line, write the 2 nd identifier & place on the specimen prior to submitting If your specimen doesn’t have a second identifier, it will NOT be processed. If your specimen doesn’t have a second identifier, it will NOT be processed.

20. Patient Identifier Needs to be unique Needs to be unique The lab suggests that sites implement a patient ID number that is composed of the date and the order of the client The lab suggests that sites implement a patient ID number that is composed of the date and the order of the client For example, the patient ID for forth client seen on 12/31/2008 could be listed as 12310804 For example, the patient ID for forth client seen on 12/31/2008 could be listed as 12310804 You may use a different formula to develop an identifier but, be sure that the identifier is unique You may use a different formula to develop an identifier but, be sure that the identifier is unique

21. Documenting Informed Consent Oregon ORSs require that non licensed health care providers/non licensed health care facilities document informed consent. Oregon ORSs require that non licensed health care providers/non licensed health care facilities document informed consent. Model consent form can be found on the web: http://www.oregon.gov/DHS/ph/hiv/informe dconsent.shtml Model consent form can be found on the web: http://www.oregon.gov/DHS/ph/hiv/informe dconsent.shtml

22. Special Scenarios

23. Rapid test with non-rapid same day confirmatory test Use one form for both tests. Use one form for both tests. Fill out: Fill out: Non-rapid specimen information Non-rapid specimen information Non-rapid tests requested Non-rapid tests requested Rapid Testing Rapid Testing

24. Anonymous rapid test followed by a confidential non-rapid confirmatory Anonymous Test Anonymous Test Confidential Test You will need to use two forms: 1-Anonymous test You will need to use two forms: 1-Anonymous test 1-Confidential test 1-Confidential test Place the rapid test form ID (test #) from the anonymous form on the line “’confirm. of prelim. pos. rapid test” located in the non-rapid test requested section of the confidential form Place the rapid test form ID (test #) from the anonymous form on the line “’confirm. of prelim. pos. rapid test” located in the non-rapid test requested section of the confidential form Risk/exposures information must be reported either on the anonymous form or the confidential form, not both Risk/exposures information must be reported either on the anonymous form or the confidential form, not both

25. Confidential rapid test followed by an anonymous non-rapid confirmatory Confidential Test Confidential Test Anonymous Test You will need to use two forms: 1-Confidential test 1-Anonymous You will need to use two forms: 1-Confidential test 1-Anonymous Place the rapid test form ID (test #) from the confidential form on the line “’confirm. of prelim. pos. rapid” located in the non-rapid test requested section of the anonymous form. Place the rapid test form ID (test #) from the confidential form on the line “’confirm. of prelim. pos. rapid” located in the non-rapid test requested section of the anonymous form. Risk/exposures information must be reported either on the anonymous form or the confidential form, not both. Risk/exposures information must be reported either on the anonymous form or the confidential form, not both.

26. Dual Rapid Testing Rapid Test Submitted Rapid Test Some testing sites occasionally conduct more than one rapid test in the same encounter. Some testing sites occasionally conduct more than one rapid test in the same encounter. In the event that two rapid tests are conducted at the same session, record both rapid tests on separate forms for site recording purposes. In the event that two rapid tests are conducted at the same session, record both rapid tests on separate forms for site recording purposes. Indicate the test form ID for the other rapid test below the rapid testing section. Indicate the test form ID for the other rapid test below the rapid testing section. Submit the form to the laboratory which drives the decision about whether to seek confirmatory testing (next slide) Submit the form to the laboratory which drives the decision about whether to seek confirmatory testing (next slide)

27. Dual Rapid Testing 1 st rapid test result 2 nd rapid test result Submit confirmation Submit form which drives confirmatory testing decision If no confirmatory testing, submit 1 st rapid test form ++YesEitherN/A +-Yes 1 st N/A +InvalidYes N/A -+Yes 2 nd N/A --NoN/A 1 st -InvalidNoN/A Invalid+Yes 2 nd N/A Invalid-NoN/A1st

28. Post-Test Disposition Form Mailing Address Mailing Address Referrals Referrals Everyone Everyone Testing Follow-up Referrals Females Form should only be completed and submitted for clients with positive non-rapid tests Form should only be completed and submitted for clients with positive non-rapid tests Do not submit this form if non-rapid test is negative Do not submit this form if non-rapid test is negative

29. Non-Rapid/Confirmatory Testing Follow-up Only submit for clients with positive non-rapid tests Only submit for clients with positive non-rapid tests Non-Rapid/ Confirmatory Testing Follow-Up Section: Non-Rapid/ Confirmatory Testing Follow-Up Section: Indicate whether results were provided to the client and if not, why Indicate whether results were provided to the client and if not, why Indicate the date of return visit Indicate the date of return visit

30. Referrals Everyone: Everyone: Indicate if referred to HIV medical care and whether an appointment was scheduled Indicate if referred to HIV medical care and whether an appointment was scheduled Indicate whether or not client was referred to Partner Services and if Partner Services had been provided Indicate whether or not client was referred to Partner Services and if Partner Services had been provided Females Only: Females Only: Indicate whether client is currently pregnant and if they are currently in prenatal care Indicate whether client is currently pregnant and if they are currently in prenatal care If client is not in prenatal care, indicate whether client was referred to prenatal care and if appointment was scheduled If client is not in prenatal care, indicate whether client was referred to prenatal care and if appointment was scheduled

31. Submitting Post-Test Disposition Form For positive non-rapid tests ONLY For positive non-rapid tests ONLY Complete and return within 30 days Complete and return within 30 days Mailing Address: Mailing Address: Oregon State Public Health Laboratory PO Box 275 Portland, OR 97207-0275 Oregon State Public Health Laboratory PO Box 275 Portland, OR 97207-0275

32. Let’s Practice!

33. CTS HIV Test Request Form Agency, Client, Test, Referral and Risk/Exposure Information

34. Let’s Practice…. Patient Information Patient Information Refuses to give DOB Refuses to give DOB Washington County, OR 99999 Washington County, OR 99999 Date of Collection: today’s date Date of Collection: today’s date Identifies as Male Identifies as Male Submitter Information Site ID: 11111 Submitter Code: 001122 Client Race & Ethnicity Declined to answer both Reason for Test Asymptomatic, self initiated

35. Let’s Practice…. Test History Test History Previously tested in 2006; results unknown Previously tested in 2006; results unknown Rapid Testing Rapid Testing Testing confidentially – his name is Brad M. Smith Testing confidentially – his name is Brad M. Smith Oral specimen taken Oral specimen taken Preliminary positive Preliminary positive Results provided and confirmatory specimen collected Results provided and confirmatory specimen collected Non-Rapid Specimen Information Non-Rapid Specimen Information Blood draw taken Blood draw taken Unique ID: Today’s date + client number (10) Unique ID: Today’s date + client number (10) Non-Rapid Tests Requested Non-Rapid Tests Requested Testing confidentially Testing confidentially

36. Let’s Practice…. Risk/Exposures Brad has had anal sex with 3 men and no women in the last 12 months, he uses condoms sometimes Brad has not has sex in exchange for money, drugs or anything of value in the last 12 months but has in his lifetime Brad has had anonymous sex in the last 12 months Brad does not know if he has ever had sex with a person who injects drugs or that is HIV positive Brad has used injection drugs in the last 12 months; he has never shared needles/injection equipment Risk Reduction & Referrals Risk Reduction & Referrals You discussed risk reduction strategies with Brad You discussed risk reduction strategies with Brad Brad declined offer for HIV prevention services Brad declined offer for HIV prevention services

37. WashingtonOR99999 25Today’s date 022006 00112211111 Name and phone number of person administering test

39. Post Test Disposition

40. Let’s Practice… A confirmatory test indicates Brad is HIV+ He was given his results on 06/17/08 Brad accepted a referral to medical care, but has not scheduled an appointment yet Brad was referred to partner services and partner services were provided

41. Check your work… 04 06 17 2008

42. Questions, Comments, Concerns? cesssa.karson@state.or.us 971-673-0150 cesssa.karson@state.or.us