Contact Tracing Form***

Questions	Concepts
Contact Tracing
Encounter & Datetime	encounterDatetime
Encounter Provider	encounterProvider
Role	encounterRole
Encounter Location	encounterLocation
Contact Method 🔘 Physical contact/client tracing 🔘 Telephone contact/client tracing 🔘 Other non-coded	166456 Mode of contact/client tracing 166457 Physical contact/client tracing 166458 Telephone contact/client tracing 5622 Other
Contacted Successfully 🔘 Yes 🔘 No 🔘 Unknown	160530 Return visit type 1065 Yes 1066 No 1067 Unknown
Outcome 🔘 Contact came for HTS 🔘 Contact will test elsewhere 🔘 Refused Test 🔘 Partner confirmed HIV+	167011 Status of call attempt 164167 HIV Test accepted 159381 Partner referred for HIV test 167156 Refused 5566 Partner confirmed HIV+
Contact booked for HIV test Yes No Unknown	159422 Patient certainty about keeping medical appointments 1065 Yes 1066 No 1067 Unknown
Date booked for HIV test ␣␣-␣␣-␣␣␣␣ 📆	160753 Date of event
Contact Tested for HIV 🔘 Yes 🔘 No 🔘 Unknown	161557 Partner HIV tested 1065 Yes 1066 No 1067 Unknown
Contact HIV Status 🔘 Positive 🔘 Negative 🔘 Indeterminate 🔘 Unknown	1436 Partner's HIV status 703 Positive 664 Negative 1138 Indeterminate 1067 Unknown
Outcome
Final Outcome reached (After successful or multiple unsuccessful tracing attempts) 🔘 Yes 🔘 No	160721 Procedure outcome 1065 Yes 1066 No
Final outcome contact tracking 🔘 Partner HIV tested 🔘 Partner confirmed HIV+ 🔘 Will test elsewhere 🔘 Contact is far from this facility 🔘 Contact unwilling to come 🔘 Dead 🔘 Unsuccessful	160433 Patient outcome status 161557 Partner HIV tested 5566 Partner confirmed HIV+ 159381 Partner referred for HIV test 160636 Lives outside of catchment area 167156 Refused 160432 Dead 166994 Unsuccessful
Contact Tracing Notes __________________________________	165095 General patient note
Outcome