Appendix III

Evaluation Modules

The cross-cutting or national evaluation for the Cooperative Agreement Projects uses a modular approach. Standardized short forms of 1-2 pages were developed for a number of different functional evaluation questions. Many of the forms were developed in a scannable form that can either be faxed for automatic entry into the database, or mailed for scanning. Data forms, received either from the fax or from the scanner, are automatically appended to the project database thus yielding data which is immediately up-to-date.

By developing very brief modules, data collection efforts for different projects are customized by including those modules that fit the purpose of the project. By using common modules across projects, as much comparable data as possible may be obtained.

In addition to the short modules, longer modules have been prepared as "standard" interview item sets, or as self-administered questionnaires. Data entry for these modules is by data entry shells developed in a standard database (Microsoft Access) and compiled so that the organization using the shell would not need to own a copy of the database. The Evaluation and Dissemination Center (EDC) provides these data entry shells to all project sites upon request to allow data entry at the site with transmission of the resulting data files to the Center. Alternately, data entry may be performed at the EDC.

Proposed Module

Purpose

Content Domains

Operational Data Items
  1. Demographics-Contact Form (FAX-IN).
  • Code major demographic characteristics of clients.
  • Code risk-background factors.
  • Code reason for form.
  • Code referrals provided at contacts.
 Race-ethnicity, gender, sexual orientation, age, reason for form, location, homeless status, HIV infection-retransmission risk factors, referrals to internal and external agencies and services. Site, Sub-Provider, Staff Code, Intake/Service Date, Client Birthdate, ID Letters/ID Numbers, Client Gender, Children, Primary Ethnic/Cultural/Racial Background, Multi-Racial, Payer Insurance, Pregnant, Highest Grade Completed, Sources of Income, Self-Identified Sexual Orientation, Marital Status, Primary Health Care Source, Employment Status, Housing Status, Incarcerated/Jail, Years Resided, Zip Code, Purpose of Contact, Primary Language, Referral Source, Behaviors, "Other" Categories
  1. Intervention Form (FAX-IN).
  • Code units of client services.
  • Code providers.
  • Code purpose of client services.
  • Code referrals provided at interventions.
  • Code medications ordered or provided.
 Types of service provided (outpatient medical, emergency room, HIV testing and counseling, mental health, social supports, etc.), providers (physician, nurse, social worker, psychologist, peer, etc.), purpose of services, referrals made to ancillary services, medications ordered or provided. Form A: Medical Services

ID Letters/ID Numbers, Site, Sub-Provider, Service Date, Staff Code, Visit or Daily Summary, Nursing Home days (RHCF or SNF), CPT Code for Type of visit (7), Ambulatory Care visits (Physician Office: Primary Care, Physician Office: Specialty Care, Health Center: Primary Care, Health Center: Specialty Care), Inpatient Medical Care days (Intensive Care Unit, Acute Care, Alternative Care), Dental Care visits (Emergency Care, Routine Care), Emergency Room visits (Urgent Care, Emergency Room, Admitted to Hospital), CPT Codes for Radiology (6), CPT Codes for Procedures (5), CPT Codes for Laboratory (12), Specialty Medical category, Durable Medical Equipment charges, Participates in clinical trials, location serves HIV+ clients only, location provides comprehensive care, Homecare visits (Homemaker, Home Health Aide, Visiting Nurse), Daycare days, Home Hospice days, Residential Hospice days, Services Provided by; Optionally include staff codes.

Form B: Psychosocial Services

ID Letters/ID Numbers, Site, Sub-Provider, Service Date, Staff Code, Visit or Daily Summary, HIV Prevention/Intervention Services, Mental Health Services, Group Counseling, Substance Abuse Services, Case Management/Advocacy, Other Services, Topics Discussed, Service Location, Services Provided by; Optionally include staff codes.

Form C: Medications Ordered or Provided

ID Letters/ID Numbers, Site, Sub-Provider, Service Date, Staff Code, Ordered or Provided, List of Medications by Generic and Brand Names.
  1. Presentations-Training Form (FAX-IN).
  • Code type of presentation.
  • Code reason for presentation.
  • Code type of audience.
  • Code number of individuals of different demographic categories impacted.
Type of presentation (group prevention, information, agency recruitment, training, advocacy, policy), type of audience (educators, community members, agency heads, CJS agencies, etc.), number of males and females of different age groups and ethnic-racial backgrounds in the audience Site, Sub-Provider, Training Number, Training Date, Hour, Minutes, Staff Providing Services, Areas of Planned Impact, Language Used

Discussion Topics: Medical Intervention and Management-Diagnosis Treatment, Psychosocial Issues-Case Management, Special Populations, Prevention of HIV Transmission, Workplace Issues, Legal Advocacy-Ethical Issues-Community-Empowerment, Personal-Interpersonal Issues, Other Categories (three), Settings, Purpose of Activity, Participants (primary caregivers, other participant groups), Individuals Served, Contacted or Reached (age and ethnicity by gender), Actual or Estimated Counts, Methods
  1. Individual Services Needed and Services Barriers Form (FAX-IN).
  • Code services needed in the last six months and last month.
  • Code services received in the last six months and last month.
  • Code reason for not seeking-receiving needed services.
 Types of services including drug detoxification, residential drug treatment, outpatient or day treatment substance abuse treatment, shelter, food or other basic needs, dentistry, scheduled outpatient and inpatient medical, emergency room services, HIV-related services, mental health, self-help, family counseling, pharmacy, vocational training, case management, HIV testing, and prenatal/pregnancy care. Barriers including cost, accessibility, transportation, lack of child care, perceived staff disdain, language, coercion, disclosure concerns. Facilitators including caring staff, child care, convenient location, and transportation. Form A: Services Needed and Received

ID Letters/ID Numbers, Site, Sub-Provider, Service Date, Staff Code, Drug detoxification or maintenance, Residential drug treatment, Outpatient or day treatment for substance abuse, Housing or shelter, Food or other basic needs, Dental services, Scheduled out-patient medical services, Emergency room services, Inpatient medical services, HIV-related medical services, HIV-related self-care services, HIV-related home care services, HIV-related hospice, Mental health services (in-patient or out-patient), Self-help group, Family counseling, Pharmacy, Vocational training, Case management, HIV testing for partner or friend, Prenatal/pregnancy care.

Form B: Barriers and Facilitators Form

ID Letters/ID Numbers, Site, Sub-Provider, Service Date, Staff Code, List of Barriers, List of Facilitators.
  1. Technical Assistance (TA) Summary Form (FAX-IN)
  • Code major aspects of technical assistance.
  • Code reason for technical assistance.
  • Code type of audience for technical assistance.
  • Code number of individuals of different demographic categories impacted.
 Type of technical assistance, type of audience, number of males and females of different age groups, ethnic-racial backgrounds, and professional service groups for whom assistance was given. Site, Sub-Provider, TA#, Date, Hour, Minutes, Staff Providing Services, Topics, Method, Materials Provided, TA Provided Directly to, Where Did the Request Come From, Purpose of Activity, Style of TA, What was requested and provided and actually needed now or in the future, Settings, Depth of TA, How TA Will Have Impact, Evaluation of TA, Appropriate Follow-ups for the Current TA Effort, Travel Required for TA, Breadth of TA, Participants, Individuals Served, Contacted or Reached (age and ethnicity by gender), Actual or Estimated Counts
  1. Technical Assistance Evaluation Form (FAX-IN)
  • Code facets of satisfaction with the TA experience.
  • Rate value of TA for knowledge in a number of areas.
  • Rate pre-TA level of knowledge in a number of areas.
  • Rate post-TA levels of knowledge in a number of areas.
 Overall satisfaction with the TA, specific dimensions of satisfaction (responsiveness, relevance, appropriateness, correct level, focus, efficiency), current knowledge levels, pre-TA knowledge levels, willingness to recommend TA for other projects and staff. Site, Sub-Provider, Date, Hour, Minutes, Staff ID for TA Provider, Rate: Recipient Knowledge about TA Topic Before Session, Quality of TA, Usefulness of TA for Work, Scope & Depth of TA, Worth Time & Effort, Recommend Similar TA to a Peer, Free Field for Additional Handwritten Comments
  1. Agency Capacity Interview
  • Code services currently provided.
  • Code services added in the last year.
  • Determine service capacities.
  • Assess likelihood of services expansion.
 Capacity for a number of services including HIV inpatient and outpatient medical, mental health, substance abuse inpatient and outpatient treatment, shelter, basic needs, social services, family counseling, and ancillary services. Clients served. Likelihood of service expansion and barriers to expansion. Date, Site Code, Program Information, Type of Agency, Activities of Agency, Services for Individuals with HIV, Services for Targeted Group, Number of Staff (total, and by type), Five items (Availability, Increased Capacity, Number of Males and Females Served, Percent Males and Females HIV-positive, Percent Males and Females in Target Group, Likelihood of Increasing Capacity for Service for Target Group) for each of 11 services (Office-Based Medical Care, Office-Based Dental Care, Mental Health Treatment, Substance Abuse Treatment, Rehabilitation Services, Case Management, Home Health Care, Hospice, Client Advocacy Services, Support Services, Education/Risk Reduction Techniques for Individuals and Groups), Barriers (19 items)
  1. Agency Infrastructure-Attitudes Form
  • Assess current attitudes about the area HIV service system.
  • Assess belief that system is integrated and enmeshed.
  • Code beliefs about equity and fairness in the service system.
  • Assess likelihood of referral to service sources.
  • Determine individual priorities for the use of HIV treatment and prevention funds.
 Determines how the individual perceives the qualities of the overall HIV service system in the area, rate how resources should be allocated. Self-Generated Unique Code of Respondent, Sex, Age, Ethnic/Cultural/Racial background, Current Job Type, Educational Background, Professional Licenses, Years of "Professional" Experience, 32 Statements About How the Service System for HIV/AIDS Services Work in a City/Region, Hypothetical Allocation of New or Extra Funds Received
  1. Agency Cohesiveness Rating Form
  • Assess knowledge about other network services.
  • Assess willingness to make referrals to services.
  • Assess likelihood of receiving referrals from other services.
  • Assess overall connections to other services.
 Determines how connected agencies in the same service system are to one another. Multidimensional scaling of perceived distances provides a mapping of the service system. Agency, Person Completing Ratings, Date, Grid 1: Knowledge of Services at Each Agency, Grid 2: Percent of Clients Referred To Each Agency, Grid 3: Percent Coming From Referrals, Grid 4: Satisfaction with Agency’s Working Relationship with Each Agency
  1. HIV Testing History Form (FAX-IN)
  • Code times of previous testing.
  • Code previous testing history.
  • Code assistance rendered at previous testing times.
  • Code client belief or nonbelief in previous HIV test results.
 Develop a timeline of the HIV testing history, determine when first tested HIV-positive, services needed at time of testing, services received at time of testing, pre- and post-test counseling history. ID Letters/ID Numbers, Site, Sub-Provider, Date, Staff Code, Client Gender, Ever Been Tested for HIV: Year This Happened, In Last Six Months, In Last 30 Days, Number of Times Tested, First Time Tested (six items), Most Recent Time (six items), Ever Tested Positive for HIV: Year This Happened, In Last Six Months, In Last 30 Days, Number of Times Tested Positive, First Time (Did Someone Help, Who Helped, Advice Given, Advice Taken), Most Recent Time (Did Someone Help, Who Helped, Advice Given, Take Advice), Ever Think You Have HIV or AIDS, Told by Doctor or Nurse: Year This Happened, In Last Six Months, In Last 30 Days, Different Times Told, Who Helped, Advice Given, Advice Taken)
  1. Satisfaction with Services: General (FAX-IN)
  • Code major aspects of satisfaction or dissatisfaction with services: general form for use with all populations.
 Overall ratings of satisfaction with services, perception of service providers, importance rankings for service issues, perceived barriers, likelihood of future use and positive recommendations to family and peers. ID Letters/ID Numbers, Site, Sub-Provider, Date, Staff Code, Method of Form Completion, Client Gender, Client Age, Client Ethnicity, Quality of Services, Quality of Information, Staff Answers, Self-Care Training, Explain Medications, Explain Side Effects, Explain Procedures, Individual Treatment, Respect Privacy, Answer Questions, Recommend to Others, Understand Special Groups, Improvement Suggestions
  1. Satisfaction with Services: Youth (FAX-IN)
  • Code major aspects of satisfaction or dissatisfaction with services: special issues for youth form.
 Covers specific issues for youth including service barriers and satisfaction with adult service providers, confidentiality from parents, appropriateness and relevance. Added to Module 11.
  1. Satisfaction with Services: Older Adult (FAX-IN)
  • Code major aspects of satisfaction or dissatisfaction with services: special issues for older adults form.
 Covers specific issues for older adults including service barriers and satisfaction with providers, appropriateness and relevance. Added to Module 11.
  1. Satisfaction with Services: Women (FAX-IN)
  • Code major aspects of satisfaction or dissatisfaction with services: special issues for women form.
Covers specific issues for women including service barriers and satisfaction with providers, appropriateness and relevance, provisions for children and families, partner services. Added to Module 11.
  1. Satisfaction with Services: Minorities (FAX-IN)
  • Code major aspects of satisfaction or dissatisfaction with services: special issues for minorities form.
 Covers specific issues for minorities including service barriers and satisfaction with providers, appropriateness and relevance, provisions for special language needs, cultural sensitivity to the client’s background, multicultural viewpoint. Added to Module 11.
  1. Standard Focus Group Characteristics Form (FAX-IN)
  • Code participant characteristics in focus groups; client conclusions.
 Covers client assessments of priorities for focus group topics. Standardized coding system for participant demographics. Site, Sub-Provider, Focus Group #, Date, Hour, Minutes, Staff Facilitators (6), Language Used, Participants (Consumers, Primary Caregivers, Other Participant Groups), Participants in Focus Group (age and ethnicity by gender), Actual or Estimated Counts, Purpose of Activity, Major Focus Group Questions and Conclusions of Participants (3 Sets of Free Field Boxes for Additional Handwritten Comments).
  1. Brief Health and Functioning Questionnaire (FAX-IN)–SF-21 Form, plus other indicators of Health-Related Quality of Life as recommended by Ron Hays
  • Code participant health problems and syndromes diagnostic of, and related to, HIV disease.
  • Code general health levels and issues.
  • Code physical symptoms and problems.
  • Measure Health-Related Quality of Life
 Health items of major relevance to HIV disease. Includes CDC indicators of stage of HIV disease. May be used for repeatedly assessing progression of HIV disease. Page 1:

ID Letters/ID Numbers, Site, Sub-Provider, Date, Staff Code, Client Gender, How Questionnaire is Completed, General Health, Overall Health, Health Kept You From Daily Activities, Health Interfered with Social Activities, Health Interfered with Certain Types of Work, Bodily Pain Interfered with Normal Work, Health Ratings (two items), Health As A Limiting Factor (four items: Vigorous Activities, Moderate Activities, Walking or Climbing Uphill, and Eating, Dressing, Bathing, or Using the Toilet), How Much of the Time Respondent Affected by Issues During the Past 4 Weeks (nine items: Limited by Physical Health, Attention Problems, Reasoning Problems, Feeling Calm, Feeling Downhearted, Feeling Tired, Having Enough Energy, Been Happy, Forgetting Things), Amount of Bodily Pain.

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ID Letters/ID Numbers, Site, Sub-Provider, Date, Staff Code, Client Gender, Number of Days Illness, Treatment, or Personal Problem Interfered (three items: Cut Down on Activities, Stayed in Bed, Missed Work), Work Last Week, Hours Worked Last Week, Personal Income, Number of Visits to Doctors, Number of Visits By Doctors, Number of Telephone Contacts with Doctors, Number of Nights at Hospital, Symptom Checklist (13 symptoms).
  1. Abbreviated HIV/AIDS Health Form (FAX-IN) – SF-21 Form only
  • Code follow-up/repeated assessments of client health, progression of disease, and Health-Related Quality of Life.
 Health items as above in an abbreviated format. Changes since last assessment. Page 1:

ID Letters/ID Numbers, Site, Sub-Provider, Date, Staff Code, Client Gender, How Questionnaire is Completed, General Health, Overall Health, Health Kept You From Daily Activities, Health Interfered with Social Activities, Health Interfered with Certain Types of Work, Bodily Pain Interfered with Normal Work, Health Ratings (two items), Health As A Limiting Factor (four items: Vigorous Activities, Moderate Activities, Walking or Climbing Uphill, and Eating, Dressing, Bathing, or Using the Toilet)

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ID Letters/ID Numbers, Site, Sub-Provider, Date, Staff Code, Client Gender, How Questionnaire is Completed, How Much of the Time Respondent Affected by Issues During the Past 4 Weeks (nine items: Limited by Physical Health, Attention Problems, Reasoning Problems, Feeling Calm, Feeling Downhearted, Feeling Tired, Having Enough Energy, Been Happy, Forgetting Things), Amount of Bodily Pain.
  1. HIV/AIDS Health Form: Women (FAX-IN)
  • Code women-specific health issues.
  • Code issues such as child-rearing, birth control, pregnancy, etc. of particular relevance to a woman’s health and functioning.
 Items particularly related to women’s health including reproductive history and medical syndromes and symptoms, STDs, other medical issues. Initial draft items distributed to Steering Committee for discussion
  1. HIV/AIDS Risk Behaviors Form (FAX-IN)
  • Code major issues of HIV risk and retransmission risk due to sexual contact.
  • Code major issues of HIV risk and retransmission risk due to injection drug use.
  • Code major issues of HIV risk and retransmission risk due to other means.
 Number of sexual partners, sex acts with and without latex protection, injection drug use, hemophilia and other blood transfers, tendency to have sex while intoxicated or high, sex trade, sexual history of sex partners. ID Letters/ID Numbers, Site, Sub-Provider, Date, Gender, Risk Behaviors Assessed for Last 24 Hours, Last 30 Days, Prior to Last 30 Days, Never, Refused, Don’t Know: Sex with Males, Unprotected Sex with Males, Sex with Females, Unprotected Sex with Females, Sex with IDU, Sex Work/Survival Sex, Sex with HIV+ Person, STD, Injection Drug Use, Needle Sharing, Received Blood Transfusion, Cigarette Smoker, Inferred Alcohol Problem, Heroin Use, Crack Use, Other Illicit Drug Use, CJS-Involved, Has Hemophilia/ Coagulation Disorder.
  1. Weekly Program Census Form (FAX-IN)
  • Method for capturing the weekly census on functional service units.
 Weekly total census, demographic characteristics of census, method of collecting census. Site, Sub-Provider, Week of, Staff Code, Total Number of Patients/ Clients This Week, Number of HIV+ Patients in Each Service Category (Males and Females separately)
  1. Quality of Life Form (FAX-IN)
  • Objective indicator of ability to engage in macro-level life activities such as being a partner, employment, attending recreational activities, etc.
  • Objective indicator of presence of sufficient resources to provide adequate standard of living.
  • Subjective indicator of self-perceived satisfaction with domain areas identified for objective indicators.
 Rated ability to fully participate in and enjoy a large number of domains of activities including employment, being a partner, sexual relationships, recreation, travel, strenuous activity – exercise, enmeshment in the community. Checklist of activities participated in during the past month. Module in draft.
  1. Follow-up Quality of Life Form (FAX-IN)
  • Follow-up version of Quality of Life Form designed for repeated use.
  • Changes in Quality of Life since previous assessment.
 Abbreviated versions of Quality of Life items listed above. Changes in QOL are specifically coded. Under development.
  1. Substance Abuse History Form (FAX-IN)
  • Standardized measure of lifetime and current substance abuse including both injection and non-injection routes of administration.
 Ever used, use in last 6 months, use in last month of: alcohol, marijuana, cocaine, heroin, crack, speedballs, amphetamines, PCP, LSD, other hallucinogens, barbiturates, other drugs. Injection drug use. Drug use during and after sexual acts. Needle sharing/cleaning behaviors. ID Letters/ID Numbers, Site, Sub-Provider, Date, Staff Code, Client Gender

Drug Use: Alcohol, Marijuana, Crack, Cocaine by itself, Heroin by itself, Heroin & Cocaine mixed together, Amphetamines, Other Drugs (ever used, age at first use, ever injected, used in the last 6 months, days used in last 30 days, days injected in last 30 days, times injected last in 30 days), Age First Injected Any Drug.
  1. Activities of Daily Living Form (FAX-IN)
  • Standardized measure to assess current ability to conduct standard living activities including meal preparation, use of telephone, handling finances, taking medication, etc.
 Checklist of activities that the client is able to do on a typical day ranging from dressing to preparing meals to driving an automobile to attending work. Designed for repeated assessments, possibly daily. ID Letters/ID Numbers, Site, Sub-Provider, Date, Staff Code, Client Gender, Items 1 through 14 (Instrumental: telephone, walking, shopping, meals, housework, medicine, money; Physical: eating, dressing, appearance, walking, getting into bed, bathing, bathroom)
  1. Current Psychological Distress Form (FAX-IN)
  • Standardized measure of psychological distress comparable to major studies conducted over 15 years throughout the U.S.: Center for Epidemiological Studies Depression Scale (CES-D).
 In last seven days: depressed, moody, blue, lonely, etc. Form A:

ID Letters/ID Numbers Site, Sub-Provider, Date, Staff Code, Client Gender, Items 1 through 20

Form B:

ID Letters/ID Numbers Site, Sub-Provider, Date, Staff Code, Client Gender, Items 1 through 8

Form C:

ID Letters/ID Numbers Site, Sub-Provider, Date, Staff Code, Client Gender, Items 1 through 4
  1. Residential Services Daily Services Form (FAX-IN).
  • Codes daily activities and services received in residential facility including treatment programs and hospices.
 Number of minutes spent in groups, milieu therapy, individual counseling, psychotherapy, family counseling, vocational training; visits to physician, psychiatrist, other professionals. Subsumed by Module 2.
  1. Outpatient Services Daily Services Form (FAX-IN).
  • Code daily activities and services received in outpatient facility and services.
 Number of minutes spent in groups, milieu therapy, individual counseling, psychotherapy, family counseling, vocational training; visits to physician, psychiatrist, other professionals. Subsumed by Module 2.
  1. Standardized Focus Group Instructions
  • Standardized specifications for conducting focus groups.
  • Suggested format for reporting focus group results.
  • Suggested questions for focus groups.
  • Suggested quantitative questions for focus groups.
 Standard grid for eliciting focus group free-responses, demographic items to code focus group participants, facilitator form to code reason for focus group and major dynamics, standardized methods for ranking alternatives. Selected by sites using guidelines for content domains.
  1. Standardized Instructions for Case Studies
  • Standardized specifications for selecting clients for case studies.
  • Suggested format for reporting case study results.
  • Suggested domains to be discussed in case studies.
  • Suggested quantitative indices to be included in case studies.
 Standard outline for case studies including patient background, major medical problems, health history, prior maximum levels of social and psychological adjustment, current psychological impairment, current physical impairment, quality of life, and ancillary problems (substance abuse, violence, homelessness, etc.). Includes information about progression of disease, quality of life, and service utilization history. Selected by sites using guidelines for content domains.
  1. Sexual Behaviors Form (FAX-IN)
  • Code current sexual practices including partners.
 Number of current male partners, number of current female partners, total sexual partners in past years, sexual partners of both sexes who were injection drug users, sex with male and female partners with and without latex protection, types of sexual practices. Site, Sub-Provider, Date, Staff Code, ID Letters/ID Numbers, Sexual Behaviors in the last month, times in last month, number of partners in last month, unprotected sex in last month: vaginal sex, performed oral sex with male partner, performed oral sex with female partner, received oral sex from male, received oral sex from female, received anal sex, had sex with IDU, performed anal sex on male partner, performed anal sex on female partner; have a main sex partner, how long with partner, how often use latex protection, survival sex
  1. Abuse History
  • Code history of physical abuse.
  • Code current levels of physical abuse.
  • Code history of sexual abuse.
  • Code current levels of sexual abuse.
  • Code any admitted behaviors as an abuser.
 Lifetime and current indicators of physical and sexual abuse from parents, other family, and strangers. Admitted abuse against others. Site, Sub-Provider, Date, ID Letters/ID Numbers, abuse coded in last 30 days, prior to last 30 days, never, refused, don’t know: Forced to have sex with family member, Physically hurt by family member, Forced to have sex with partner when respondent did not want to, Forced to have sex with stranger, Sex partner threatened to physically hurt respondent, Sex partner physically hurt respondent, Sex partner hurt respondent in some other way, Used drugs with sex partner for fear of being hurt; additional items to be developed.
  1. Self Esteem
  • Code current levels of self esteem.
 Use major, multidimensional self esteem scale. (Rosenberg) ID Letters/ID Numbers, Site, Sub-Provider, Date, Staff Code, Client Gender, Items 1 through 10
  1. Partner Disclosure Risk Form (FAX-IN)
  • Code likelihood of being recipient of partner violence if HIV status is disclosed.
 Indicators of potential partner psychological, verbal, and physical violence at disclosure of HIV status. ID Letters/ID Numbers, Site, Sub-Provider, Date, Staff Code, Client Gender, HIV Status, Disclosed Status to Partner, (if disclosed) Partner Reactions, (if not disclosed) Perceived Partner Reactions, Intent to Disclose, Timeline of Disclosure
  1. Homelessness Index
  • Code stability of current housing situations.
  • Code history of housing stability.
 Time history of places lived and with whom, log of places slept in the last year and month, use of shelters, ability to support a permanent home. ID Letters/ID Numbers, Site, Sub-Provider, Date, Staff Code, Client Gender, Homeless Status, Time Homeless, Lived Alone or With Someone, With Whom Lived, First Time Without Home, Year Last Homeless, Sleep/Rest Places (six items), Place Slept Last Night, Length at Shelter, Expected Next Time With Home, Ever Thrown Out of Sleeping Place, Ever Thrown Out of Service Provider, Income Last Month, Help Received Last Month (three items), Time Without Food Last Month
  1. Family Composition Form (FAX-IN)
  • Code current and past family members.
  • Code major aspects of family functioning including cohesiveness, support, stability.
 History of children, partners, siblings, parents, extended family. Ratings of current family problems and strengths. ID letters/ID Numbers, Site, Sub-Provider, Date, Staff Code, Client Gender, Have a Lover/Partner/Spouse, Have Children, People Living in Household, Ability to See Individuals in Social Support Network, 9 attitude statements, Health of Those with HIV, Ability to Obtain Services, Services Needed and Received for Self, Others in Family with HIV, Others in Family Who Do Not Have HIV
  1. Personality Test Battery
  • Code major dimensions of psychological functioning
 Basic Personality Inventory. Includes dimensions for thought disorder, depression, alienation, denial, and social introversion. Same as content domains; 240 items.
  1. Suicide Probability
  • Standardized indicator of suicide potential.
 Suicide Probability Scale. Same as content domains.
  1. Emotional Functioning Battery
  • Standardized measure of present mood and emotional state.
 Profile of Mood States or alternative. Same as content domains.
  1. Cognitive/Neurological Test Battery
  • Screening test for neuropsychological impairment.
 Screening test for the Luria-Nebraska Neuropsychological Battery (LNNB-ST). Indicates likely pathology in a full neuropsychological workup. Same as content domains.
  1. Standardized Nutrition Schedule (FAX-IN)
  • Standardized nutrition recording form permitting an estimate of calories consumed.
 Overall schedule of food consumed, total calorie estimate, hunger, desire to eat. Form A: Food and Eating Habits

ID Letters/ID Numbers, Site, Sub-Provider, Date, Staff Code, Client Gender, DOB, Eating Habits (4 categories), Food Preparation Items, Food Shopping Practices (6 categories), Weight & Body Image, 23 attitude statements concerning food and nutrition. Form is currently 3 letter-sized pages.

Form B: Nutrition Questionnaire

Checklist of how often various food categories are eaten. Form is currently 3 letter-sized pages.
  1. Psychosocial Observations Form (FAX-IN)
  • Code perceived level of cognitive, social, intellectual functioning.
  • Code appearance, obvious behavior problems, emotional state.
  • Code manner of speaking.
 Ratings of functioning levels; behavioral descriptions of emotional state, appearance, stated problems, inferred problems, manner of speaking, possible intoxication, disorganization. ID Letters/ID Numbers, Site, Sub-Provider, Date, Staff Code, Client Gender, Items 1 through 8, Items A through D (Other categories)
  1. Clinical Observations Form (FAX-IN)
  • Code perceived levels of behavioral, mental, and health problems.
  • Code unusual incidents.
  • Code changes in status.
 Ratings of clinical problem levels conducted by clinical staff. Goes beyond psychosocial observations by requiring trained clinical inference. ID Letters/ID Numbers, Site, Sub-Provider, Date, Staff Code, Client Gender, Items 1 through 17
  1. Progress Ratings Form (FAX-IN)
  • Code progress of deterioration, HIV disease, or adherence to treatment regimens.
  • Code barriers to progress.
  • Code client satisfaction with progress.
 Ratings of overall progress including changes. Site, Sub-Provider, Date, Staff Code, ID Letters/ID Numbers, Karnofsky Scale, Rating of Patient/Client Adherence to Treatment, Barriers to Adherence, Level of Patient/Client Satisfaction with Progress
  1. Life Stressors Form (FAX-IN)
  • Standard measure of the presence of significant sources of life stress
 Checklist of major life stressors and valence associated with each. Site, Sub-Provider, Date, Staff Code, ID Letters/ID Numbers, a list of events that the client may or may not have experienced, ratings of the severity of each of the events.
  1. Social Supports Form (FAX-IN)
  • Standard measure of the presence and importance of sources for social support.
 Ratings of support from partner, children, parents, other family, HIV-positive individuals, church, employer, male friends, female friends, etc. Site, Sub-Provider, Date, Staff Code, ID Letters/ID Numbers, who (up to 9 individuals) provides certain types of social support, ratings of satisfaction with each of the six social support networks.
  1. Coping (FAX-IN)
  • Standard indicators of modes of coping with stress and illness.
 Assessment of coping through denial, projection, discounting, emotional leveling, and other methods. Coping will be assessed both as a general theme and in terms of coping with HIV disease. Under development.
  1. Resources to Deal with HIV Disease
  • Assessment of financial resources to cope with HIV disease.
  • Health insurance, disability benefits, "negative" life insurance benefits.
 Income from work, relatives, annuities, disability insurance, selling death benefits. Self perceived adequacy of these sources of income to provide adequate quality of life and medical care. Under development.
  1. Staff Characteristics Form
  • Major demographic characteristics of staff service provider.
  • Experiential background of service provider.
  • Educational background of service provider.
  • Major "treatment philosophy" of service provider.
 Staff race-ethnicity, age, gender, sexual orientation, similarity to target groups (HIV-positive, drug abuser, mental health diagnosis), educational background, ratings of agreement with treatment practices and philosophy items. Site, Sub-Provider, Date, Hour, Staff Code, Completed By, Gender, Age, Primary Ethnic/Cultural/Racial Background, Multi-Racial, Professional Credentials, Primary Language, Organization Type, Primary Involvement with HIV+ Individuals, Years of Professional Experience, Years of Professional HIV Experience, Where Clients Come From, Number of Persons with HIV/AID Personally Treated, Hours of HIV/AIDS Education, Highest Level of Education, Primary Functional Role in Job, Sexual Orientation (three items), HIV status (three items)
  1. Future Plans Form (FAX-IN)
  • Perceived desire and likelihood engaging in major life events in the next 12 months.
 Ratings of perceived likelihood and desirability of major life events including holding a job, parenting, having a child, travel, forming new friendships, doing volunteer activities, etc. Under development.
  1. Referral Form (FAX-IN)
  • Codes referrals made to participating social service agencies.
 Tracking of referrals for social services, mental health, substance abuse treatment, basic needs services, etc. ID Letters/ID Numbers, Site, Sub-Provider, Referral Date, Staff Code, Gender, Generic list of referral agencies (to be customized for each site), List of Referral Categories, "Other" Referrals
  1. Cost Effectiveness Guidelines
  • Guidelines for calculating cost effectiveness statistics.
 Standardized directions and definitions for calculating cost-effectiveness. Set of procedures and guidelines.
  1. Trainee Characteristics Form (FAX-IN).
  • Code major demographic characteristics of trainees.
  • Code professional background.
  • Code prior experience/knowledge of HIV/AIDS issues.
 Ethnic-racial, age, types of professional training and degrees, professional identification and licensure, experience with clinical aspects of HIV/AIDS, experience with HIV/AIDS prevention techniques. ID Letters/ID Numbers, Site, Training Number, Training Date, Primary Ethnic/Cultural/Racial Background, Age, Gender, Professional Credentials, Organization Type, Primary Language, Taking Training to Train Others, Likely to Use Training to Train Others, Talking Training to Change Personally Access Services, Likely to Use Training to Personally Access Services, Years of "Professional" Experience, Highest Level of Education, Where Most Clients Come From, Primary Functional Role in Job, Primary Involvement with HIV+ Individuals, Age, Gender, Sexual Orientation, HIV-positive, Number of persons with HIV/AIDS Personally Served in Past Year, Number of Hours of HIV/AIDS Education Training in Past Three Years, Comfort in Providing Services (5 items)
  1. Trainee Reactions to Training Form (FAX-IN)
  • Code major facets of satisfaction with the training experience.
  • Code training satisfaction with trainers.
  • Rate value of training for knowledge in a number of HIV/AIDS-related areas.
 Satisfaction with training, connection with trainers, perceived utility of information-skills presented, value of training and relevance for own job. Site, Sub-Provider, Training Date, Training #, Title of Training, ID Letters/ID Numbers, Rating of knowledge level prior to attending session, Was session worth time and effort, Recommend session to a peer; For up to 3 individual trainers: Trainer ID, Name of Speaker, Rate speaker’s knowledge level on topic, Quality of presentation, Usefulness of session for work, Rate level of difficulty of session, Free field box to write in additional comments
  1. Trainee Reactions to Training Follow-up Form (FAX-IN)
  • Short version of above used for temporal follow-up.
 Satisfaction with training, connection with trainers, perceived utility of information-skills presented, value of training and relevance for own job. Site, Sub-Provider, Training Date, Title of Training, ID Letters/ID Numbers, Training #, Have you used information from the training & how, Intend to use information from training in the future, Rate level of knowledge prior to attending training, Rate level of knowledge after attending training, Rate presenters’ level of knowledge, Quality of session, Usefulness for work, Difficulty level, Worth time & effort, Recommend session to a peer, Free field box to write in additional comments.
  1. Trainer Characteristics Form (FAX-IN).
  • Major demographic characteristics of trainer.
  • Experiential background of trainer.
  • Educational background of trainer.
  • Major "philosophy" of trainer.
 Trainer race-ethnicity, age, gender, sexual orientation, similarity to target groups (HIV-positive, drug abuser, mental health diagnosis), educational background, ratings of agreement with practices and philosophy items. Site, Sub-Provider, Training Number, Training Date, Hour, Staff Code, Completed By, Client Gender, Age, Primary Ethnic/Cultural/Racial Background, Multi-Racial, Professional Credentials, Primary Language, Organization Type, Primary Involvement with HIV+ Individuals, Years of Professional Experience, Years of Professional HIV Experience, Where Clients Come From, Number of Persons with HIV/AID Personally Treated, Hours of HIV/AIDS Education, Highest Level of Education, Primary Functional Role in Job, Sexual Orientation (three items), HIV status (three items)
  1. Training Evaluation Form: Knowledge, Attitudes, Comfort (FAX-IN)
  • Code major areas of HIV/AIDS knowledge.
  • Code attitudes toward HIV/AIDS and related conditions.
  • Code self-perceived comfort dealing with topics related to HIV/AIDS.
 Standardized scale of HIV/AIDS knowledge for health care professionals.

Standardized scale of attitudes toward HIV/AIDS and related conditions.

Standardized scale of degree of comfort in addressing HIV/AIDS topics.

 Rate ability to counsel clients before and after this training; manage clients before and after this training; comfort level in address this training topic before and after this training.
  1. Training Evaluation Form: Knowledge, Attitudes, Comfort Follow-up (FAX-IN)
  • Short version of above used for temporal follow-up.
 Alternate and/or abbreviated form of Module 57. Alternate and/or abbreviated form of Module 57.
  1. Training Evaluation Form: Standardized Scenarios for HIV/AIDS Training
  • Standardized scenarios in AIDS Care, HIV Prevention, Referrals, Related Conditions-Diseases, Current Therapies, Needs of Special Groups
  • Code knowledge, attitudes, skills, comfort
 Brief (1-2 paragraph) constructed to assess major issues in patient care, HIV prevention, and related issues. Each scenario followed by 6-12 questions assessing knowledge, attitudes, skills, and comfort in dealing with the topic. Under development.
  1. Training Evaluation Form: Standardized Scenarios for HIV/AIDS Training
  • Alternate versions of above used for temporal follow-up.
 Brief (1-2 paragraph) constructed to assess major issues in patient care, HIV prevention, and related issues. Each scenario followed by 6-12 questions assessing knowledge, attitudes, skills, and comfort in dealing with the topic. Under development.
  1. Hotline Client Background and Referral Form (FAX-IN)
  • Codes client calls to a hotline or agency when such calls constitute a service.
  • Codes referrals made to participating social service agencies.
 Tracking of client characteristics and nature of the call. Tracking of referrals for social services, mental health, substance abuse treatment, basic needs services, etc. ID Letters/ID Numbers, Site, Sub-Provider, Date, Client Initials, Gender, DOB, Racial/Ethnic Identity, Staff Code, Phone Inquiry, Phoneline, Topics Discussed, Minutes, Generic List of Referral Agencies (to be customized for sites), Referrals Made for, "Other"
  1. Chart Review Standards
  • Codes major variables related to physician and other health care provider practices from medical chart.
  • Codes major variables related to client stage of HIV disease from medical chart.
 To be determined. Under consideration for development.
  1. HIV Status Report, AIDS Related Variables
  • Codes major HIV disease related variables on a single form.
  • Items taken from HRSA Uniform Reporting System (URS).
 CDC-defined disease stage, CD4 count, source of status, exposure category, TB status. ID Letters/ID Numbers, Site, Sub-Provider, Date, Staff Code, Client Gender, CD4 Plus Lymphocyte Count, HIV Status, Source of CD4 Count, Initial or Update, 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, CD4 Plus Lymphocyte Count, HIV Exposure Categories –Adult/Adolescent (four items) and Pediatric (three items)
  1. Self Efficacy Scale
  • Codes feelings of mastery
 Standardized scale with known reliability and validity. ID Letters/ID Numbers, Site, Sub-Provider, Date, Staff Code, Client Gender, Items 1 through 7
  1. Acceptance of Disease Scale
  • Codes level of acceptance of HIV disease.
  • Codes ability to view the successes and positive impact of one’s life.
  • Codes feelings that previously unresolved issues related to family and friends have been resolved.
 To be determined. Under consideration for development.
  1. Training Evaluation Form: Characterization of Training Form
  • Codes training topics.
  • Codes training methods.
  • Codes units of training.
 THIS PROPOSED MODULE WAS COMBINED WITH MODULE 3 DURING THE CONFERENCE CALLS. NOT USED. Subsumed by Module 3
  1. General Well Being Scale
  • Codes feelings of well being in a number of different areas of life.
 Standardized scale by Andrews and Withey and used in General Social Survey since 1976. National data available. Used in hundreds of studies. ID Letters/ID Numbers, Site, Sub-Provider, Date, Staff Code, Client Gender, Item 1 (General Satisfaction), Items 2 through 20
  1. Program Discharge Form
  • Codes discharge date.
  • Codes reasons for program discharge.
 Reasons for discharge including voluntary and involuntary withdrawal from the program, movement from service area, death. ID Letters/ID Numbers, Site, Sub-Provider, Date, Staff Code, Client Gender, Discharge Date, Reason for Discharge
  1. Suggested standards for ethnographic research
  • Defines major issues and standards for ethnographic research.
 Differentiates ethnographic research from other forms of qualitative research. Selected by sites using guidelines for content domains.
  1. Short Health Rating Form
  • The purpose of this module is to made a quick assessment of health at a given point in time.
 Codes client’s rating of overall health, CD4 count, and Karnofsky rating. Subsumed by Module 73.
  1. Medical Health Form
  • The purpose of this module is to assess medical health conditions that are related to HIV disease.
 Items are adapted from Adolescent SPNS National Evaluation; Codes HIV-related conditions such as PCP, MAI, TB, and other health problems. Under development; see content domains.
  1. Missed Visit/ Appointment Form
  • The purpose of this module is to record missed appointments or office visits by a client. This is a key issue in tracking adherence to program advice.
 Codes type of appointment missed and reason missed. ID Letters/ID Numbers, Site, Sub-Provider, Date of Visit/Appointment, Staff Code, Type of Visit, Location of Visit, Reason for Missed Visit/Appointment, Has client missed two consecutive visits, Action(s) Taken by Client, Action(s) Taken or Attempts Made to Encourage Client to Keep Appointment(s), Date Provider Last Attempted to Reach Client, Number of Attempts Made
  1. Karnofsky and Disease Stage Scale
  • The purpose of this form is to code stage of disease, CD4 count, and Karnofsky ratings for a client.
 Graphically represents stage of disease as a function of CD4 count; also includes annotated Karnofsky rating scale. ID Letters/ID Numbers, Site, Sub-Provider, Date, Staff Code, Client Gender, CD4 Count, Opportunistic Infections Associated with Various Stages of Disease, Karnofsky Rating
  1. Urinalysis Report Form
  • The purpose of this form is to record the results of urinalysis that may be conducted as part of monitoring for use of alcohol or other drugs.
 Codes substances detected and confirmed via urinalysis. Does not specify which assay method is used in the urinalysis. ID Letters/ID Numbers, Site, Sub-Provider, Date, Staff Code, Date of Urinalysis, Drugs Detected and Confirmed (with option for Negative for All Drugs)

 

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