Partner Notification Form

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 1535 Female gender 1534 Male gender
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 1528 Child 105 Intravenous drug use 5617 Partner or spouse
Contacts HIV Status
What is the contact HIV status as reported by the Index 🔘 Positive 🔘 Negative 🔘 Unknown	1436 Partner's HIV status 703 Positive 664 Negative 1067 Unknown
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 1065 Yes 1066 No
Has this person ever threatened to hurt you? 🔘 Yes 🔘 No	bd86f7ee-1d5f-4f5d-aa0f-4680aa6e65cb 1065 Yes 1066 No
Has this person ever forced you to do something sexually that made you feel uncomfortable? 🔘 Yes 🔘 No	123160 Victim of sexual aggression 1065 Yes 1066 No
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