Module 63: HIV Status Report Form

A Module Used in The Measurement Group's Cross-Cutting Evaluation of the HRSA HIV/AIDS Bureau's Special Projects of National Significance on Innovative Models of HIV/AIDS Care

Purpose

• Codes major HIV disease related variables on a single form.
• Items taken from HRSA Uniform Reporting System (URS).

Content Domain - CDC-defined disease stage, CD4 count, source of status, exposure category, TB status.

Operational Data Items - ID Letters/ID Numbers, Site, Sub-Provider, Date, Staff Code, Client Gender, CD4 Plus Lymphocyte Count, Source of CD4 Count, Initial Intake or Update/ Change, HIV Status, Source of HIV Status, AIDS Status, Source of AIDS Status, TB Status, TB Treatment Status, PPD Performed Last Year, Result of PPD Performed Last Year, Client Anergic, CDC Defined Disease Stage–Adult/Adolescent, CDC Defined Disease Stage–Pediatric, HIV Exposure Categories–Adult/Adolescent (four items) and Pediatric (three items).

Citation - Huba, G. J., Melchior, L. A., Staff of The Measurement Group, and HRSA/HAB's SPNS Cooperative Agreement Steering Committee (1996). Module 63: HIV Status Report Form. Available: www.TheMeasurementGroup.com. Culver City, California: The Measurement Group.

Usage - Permission is granted for non-commercial use so long as form is not altered, the copyright is not removed, and a proper citation is made to the instrument. Non-commercial use is use by a not-for-profit organization in which the instrument is not sold. If you have questions about appropriate and proper uses, contact The Measurement Group.

Findings from Evaluating HIV/AIDS Programs

Reliability and Validity Studies