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Questions

Concepts

Contact’s Information

Encounter Date

␣␣-␣␣-␣␣␣␣ 📆

160753 Date of event

Contact's First Name

___________________________

166102 First name

Contact's Middle Name

___________________________

166574 Middle name

Contact's Last Name

___________________________

166103 Last name

Gender

🔘 Female

🔘 Male

166025 Sex at birth

Phone Number

___________________________

159635 Contact phone number

Address

___________________________

160632 Free text general

Index Typology

Relationship

🔘 Child

🔘 Drug Injecting Partner

🔘 Sexual Partner

1061 Method of hiv exposure

Contacts HIV Status

What is the contact HIV status as reported by the Index

🔘 Positive

🔘 Negative

🔘 Unknown

1436 Partner's HIV status

IPV Assessment

Within the past year, has this person ever hit, kicked, slapped, or otherwise physically hurt you?

🔘 Yes

🔘 No

138574 History of physical abuse

Has this person ever threatened to hurt you?

🔘 Yes

🔘 No

bd86f7ee-1d5f-4f5d-aa0f-4680aa6e65cb

Has this person ever forced you to do something sexually that made you feel uncomfortable?

🔘 Yes

🔘 No

123160 Victim of sexual aggression

Partner Notification Approach

PNS Strategy

🔘 Passive Referral

🔘 Dual Referral

🔘 Provider Referral

🔘 Contract Referral

169427 Partner Notification Services referral approach

169425 Passive referral approach

169424 Dual referral approach

169426 Provider referral approach

169423 Contract referral approach

Date by which the contact should have been notified of exposure

␣␣-␣␣-␣␣␣␣ 📆

160753 Date of event

Notes

IPV Notes

___________________________

165095 General patient note