Purpose

• Code major demographic characteristics of clients.
• Code risk-background factors.
• Code reason for form.
• Code referrals provided at contacts.

Content Domain - 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.

Operational Data Items - 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, Children, Referral Source, Behaviors, "Other" Categories.

Citation - Huba, G. J., Melchior, L. A., Staff of The Measurement Group, and HRSA/HAB's SPNS Cooperative Agreement Steering Committee (1997). Module 1: Demographic-Contact 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