Service Delivery Model Form

Questions	Concepts
Enrollment/Disenrollment filter question***
Date enrolled to DSD ␣␣-␣␣-␣␣␣␣ 📆	160753 Date of event
Date disenrolled from DSD ␣␣-␣␣-␣␣␣␣ 📆	160753 Date of event
Reason for disenrolling from DSD __________________________________	163513 Reason for discontinuing service (text)
Antiretroviral treatment refill model 🔘 Community medication distribution, healthcare worker led 🔘 Community medication distribution, peer led 🔘 Express pharmacy pickup without clinician visit 🔘 Facility group medication distribution 🔘 Standard pharmacy pickup following clinician visit	166448 Antiretroviral treatment refill model 166443 Community medication distribution, healthcare worker led 166444 Community medication distribution, peer led 166446 Express pharmacy pickup without clinician visit 166445 Facility group medication distribution 166447 Standard pharmacy pickup following clinician visit
Notes __________________________________	165095 General patient note