CONTACT FORM INSTRUCTIONS - TheMeasurementGroup.com

ADOLESCENT SPNS PROJECT

CONTACT FORM INSTRUCTIONS

Use a black writing instrument (pen or pencil) to complete this form. Answer questions by either filling in a circle, or writing a number or letter in a square box. If the answer goes in a square box, you must use a CAPITAL LETTER or number that does not touch the side of the box. Print only one letter or number in each box. Make the letter or number look like those in the boxes on the Instructions form. If they do not, the computer cannot read your answers. If the letters or numbers that you print touch the sides of the boxes, or if you do not clearly print the information, the computer will "kick out" the form and we will need to return it to you to be completed correctly. If the question asks the answer to be filled in a circle, make sure that the circle is completely darkened.

Specific Parts of the Contact Form

SPNS SITE. This is a code to identify your project in the cross-cutting evaluation. It should be pre-printed on the form. If it has not been already entered on the form, check with your project to find out your site code and enter it in the boxes. Site codes are 2 or 3 letters.

PROVIDER. Enter the code for the service provider agency doing the activity. The provider codes are on a separate sheet. Provider codes are 2 or 3 letters.

STAFF CODE. Enter the staff member code or codes for each of the staff providing services. The staff codes are on a separate sheet. If there is a combination of 2 or more staff members providing the service, the staff codes for combinations of staff should be used. Staff codes are 3 numbers.

SERVICE DATE. Enter the numbers representing today's date (the date of the activity) in these boxes. Enter the month as a number from 01 to 12 for January through December. Enter the day as a two-digit number (01 to 31). Enter the last two digits of the current year (for example, "94" for 1994). Make sure that if a month or day is less than 10, you place a "0" before the number.

HOUR. Enter the approximate time that the activity started in these boxes. Use a "0" as a place holder if you use a number less than 10. Then darken the circle to indicate AM or PM. For example, if the activity occurred at 1:30 in the afternoon, enter "01" for Hour and darken the circle next to "PM." Round the time to the nearest hour. For example, 12:31 to 1:30 is entered as "01" to indicate 1:00. Do not enter the time in military or 24-hour format (such as 13:00).

LENGTH MINUTES. Enter the number of minutes that the activity lasted in these three boxes. If the activity lasted less than 100 minutes, enter a "0" before the number of minutes. For example, if the activity lasted 25 minutes, you would enter "025"; if it lasted 5 minutes, you would enter "005."

CLIENT CODE. If your site is using the unique identifier proposed by The Measurement Group, print the first and last initials of the person you have contacted in the first two boxes. If he or she does not want to tell you his/her initials, leave these boxes blank. Leave the rest of the boxes for "CLIENT CODE" blank.

If your site is not using the unique identifier proposed by The Measurement Group, use the boxes next to "CLIENT CODE" to enter the unique identifier your site is using. See specific instructions for your site.

GENDER. Darken the circle next to "Male" or "Female" to indicate the respondent's gender.

CLIENT BIRTHDATE/AGE. Where the boxes specify, enter the numbers representing the respondent's birth date. Enter the month as a number from 01 to 12 for January through December. Enter the day as a two-digit number (01 to 31). Enter the last two digits of the birth year (for example, "70" for 1970). Make sure that if a month or day is less than 10, you place a "0" before the number. If the respondent does not want to tell you his/her birth date, leave these boxes blank. If you do not know the respondent’s birthdate, fill in his/her age in the boxes labeled "Month/Age" and leave the "Day" and "Year" boxes blank. Estimate the age if the respondent does not tell you him or herself. You must enter birthdate if you are using the TMG unique identifier.

REASON FOR CONTACT FORM. Darken the circle next to the type of contact that describes this activity. Fill in the circles for all that apply.

Outreach. Darken this circle if the person was contacted through an outreach program.

Formal Enrollment. Darken this circle if the person is enrolling in your program. An individual is enrolled in the program when he or she agrees to return and participate in the program. Formal enrollment implies that the participant will develop rapport with program staff and fully participate in the intervention.

Program Discharge. Darken this circle if the person is leaving your program. Darken this circle if this is the last session with this participant. The discharge can be a program completion, a voluntary departure, or an involuntary discharge from the program.

Casual. Darken this circle if the person does not want to participate in the program or if he or she is not sure about participating and does not want to give you personal information.

Phone Call. Darken this circle if the contact was done over the phone.

Change. Darken this circle if this Contact Form is to record changes in the record of a person who has already been contacted and has a previous Contact Form on record. For example, if you discover after several sessions that a female participant is pregnant, complete a new contact form, being sure to mark the circles next to "Change" and "Pregnant" in addition to the usual information about the client initials, gender, birthdate, and all information requested at the top of the form.

Topics Discussed. For the items listed under "Topics Discussed," darken the circle next to all of the topics that were discussed with the person during the contact. For example, if you discussed HIV Risk Factors with the person, you would darken the circle labeled "HIV Risk Factors." If you discussed a topic that is not listed here, write in a short description of the topic in the boxes labeled "Other."

HIV Risk Factors. Darken this circle if the topics discussed related to HIV risk factors, including but not limited to sexual behaviors, injection and other drug use, blood sharing, and other factors that increase a person's risk for HIV.

"Safer" Sex. Darken this circle if the topics discussed related to "safer sex" and ways to reduce risk through using latex protection and less risky sexual behaviors.

HIV Testing. Darken this circle if the topics discussed related to getting HIV testing, what the test means, pre- and post-test counseling, implications of getting tested, and other related topics.

HIV Services. Darken this circle if the topics discussed related to getting prevention, intervention, and/or treatment services for HIV for oneself or someone else.

Medical Services. Darken this circle if the topics discussed related to health and medical services in general, not necessarily specific to HIV or AIDS.

Public Assistance. Darken this circle if the topics discussed related to getting benefits the person may be eligible for, such as welfare, AFDC, food stamps, etc.

Alternate Therapies. Darken this circle if the topics discussed related to alternative therapies including herbals, acupuncture, Chinese medicine, etc.

Family Planning. Darken this circle if the topics discussed related to contraception/birth control advice and services, and related family planning issues.

Substance Abuse. Darken this circle if the topics discussed related to alcohol and other drug abuse, including but not limited to prevention, identification of abuse, intervention and treatment services, links between substance abuse and HIV, 12-step groups, and other related issues.

Emotional Problems. Darken this circle if you discussed mental or emotional problems.

"Hassles." Darken this circle if the topics discussed related to problems in general; not specifically identified in terms of the other categories listed. Includes relationship problems with family and peers.

Assertiveness. Darken this circle if the topics discussed related to assertiveness. May include learning to be more assertive.

Housing/Jobs. Darken this circle if the topics discussed related to obtaining housing or jobs. May include job skills, vocational training, etc.

Enrollment. Darken this circle if you discussed enrolling in your program with the individual.

Self Identity. Darken this circle if the topics discussed related to identity and sexual orientation.

Youth Empowerment. Darken this circle if the topics discussed related to teaching youth skills to negotiate the service system on their own. This is similar to advocacy, but in youth empowerment the youth learns how to advocate for him or herself.

Living with HIV. Darken this circle if the topics discussed related to living with HIV disease. Can refer to oneself or a family member or friend.

Health Status. Darken this circle if the topics discussed related to the respondent's health.

Dating/Sex. Darken this circle if the topics discussed related to dating, relationships, and sex.

Risk Reduction Barriers. Darken this circle if the topics discussed related to barriers to reducing one's risk of HIV. Includes reasons why it is hard for youth to change risky behaviors.

RACIAL/ETHNIC IDENTITY. Darken the circle for the category that best describes the person's ethnic/racial background. If the person is multi-racial, you may darken more than one circle. Darken the circle next to "Other/Don't Know" if you cannot tell the person's racial or ethnic identity or their identity does not fit into the categories listed.

ITEMS PROVIDED AT THE CONTACT. Darken the circle next to all of the items that were available at the activity. For example, if brochures and condoms were available, you would darken the circle next to "Brochures" and the circle next to "Condoms." If you provided an item that is not listed here, write in a short description of the item in the boxes labeled "Other."

Brochures. Darken this circle if brochures, pamphlets, or flyers were provided. Any short printed material can be counted as a brochure.

Other Educational Materials. Darken this circle if other educational materials were provided (not brochures, service directories, or wallet cards).

Referral Lists/Directories. Darken this circle if you provided referral lists or service provider directories.

Wallet Cards. Darken this circle if you provided a wallet card or other small card with information about hotlines, service provider agencies and other programs.

Immunizations. Darken this circle if you provided immunizations for the participants.

Medications. Darken this circle if medications were prescribed or provided directly to participants.

Condoms. Darken this circle if you provided condoms.

Dental Dams. Darken this circle if you provided dental dams.

Bus Tokens/Transport. Darken this circle if you provided bus tokens, transportation or vouchers (such as taxi vouchers).

Food/Vouchers. Darken this circle if you provided food or food vouchers.

Bleach. Darken this circle if you provided bleach or bleach kits.

SELF-IDENTIFIED SEXUAL ORIENTATION. Darken the circle next to the phrase that best describes the person's sexual orientation. Darken only one circle for this question. Mark "Undecided" if the person is not sure. Mark "Refused" if the person refuses to indicate his/her sexual orientation to you.

CONTACT LOCATION. Darken the circle next to the place where the contact occurred. If it was not at one of the locations listed here, enter a brief description of the place in the boxes next to "Other." Darken only one circle to indicate the contact location.

Street. Darken this circle if the contact took place outside on the street or in a park.

CBO. Darken this circle if the contact took place at a community based organization or agency.

Shelter/Drop-In. Darken this circle if the contact took place at a shelter or drop-in facility.

Clinic. Darken this circle if the contact took place at a clinic.

Hospital. Darken this circle if the contact took place at a hospital.

Telephone. Darken this circle if the contact took place over the telephone.

Home. Darken this circle if the contact took place in a residence or home.

Job. Darken this circle if the contact took place at a job or place of employment.

Restaurant. Darken this circle if the contact took place in a restaurant (fast food or other).

Bar/Club. Darken this circle if the contact took place in a bar or night club.

IN THE FOLLOWING SECTION, DARKEN THE CIRCLE NEXT TO ANY DESCRIPTION THAT APPLIES TO THE PARTICIPANT. Darken the circle if you think or know that it describes the participant, whether he/she has told you or based on your observations.

Homeless. Darken this circle if you think it describes the person's situation, from what the person has told you, or from what you observe.

Runaway. Darken this circle if you think it describes the person's situation, from what the person has told you, or from what you observe.

CJS Involved. Darken this circle if the person is or was on probation, parole, or had another type of criminal justice involvement within the past year, based on what the person told you or from what you observe.

MHS Involved. Darken this circle if the person has had treatment, counseling, or hospitalization for a mental health problem within the past year, based on what the person told you or from what you observe.

Transgender. Darken this circle if the person is transgendered.

Pregnant. Darken this circle if the person is pregnant at the time of contact (females only).

Hemophiliac. Darken this circle if the person is a hemophiliac.

In JHS/HS. Darken this circle if the person is in junior high or high school.

In College. Darken this circle if the person is in college.

Partner Issues. Darken this circle if the person is in an abusive or otherwise inappropriate relationship with a romantic or sex partner.

First Intervention Also Given. Darken this circle if an Intervention Form was also completed on the day of this contact.

BEHAVIORS. For each of the items listed here, enter the letter code that describes the person's experiences with that item. Enter a "C" in the box if the item has happened to them and it occurred within the last 30 days. Enter a "E" in the box if the item has happened to them and it occurred more than 30 days ago. Enter a "N" in the box if the item never happened or if the behavior does not apply. Enter a "R" in the box if the person refused to tell you or they did not know. For example, if the person had sex with males within the last 30 days, you would write "C" in the box to the left of the label "Sex with Males."

Sex with Males. Enter the letter that best describes the person's experience with having sex with males.

Unprotected Sex with Males. Enter the letter that best describes the person's experience with having sex with males without using latex protection.

Sex with Females. Enter the letter that best describes the person's experience with having sex with females.

Unprotected Sex with Females. Enter the letter that best describes the person's experience with having sex with females without using latex protection.

Sex with IDU. Enter the letter that best describes the person's experience with having sex with a partner who injects drugs.

Survival Sex. Enter the letter that best describes the person's experience with having sex in exchange for food, money, or a place to stay.

Sex with HIV+ Person. Enter the letter that best describes the person's experience with having sex with a partner who is known to be infected with HIV.

STD. Enter the letter that best describes the person's experience with having a sexually transmitted disease.

Substance Abuse. Enter the letter that best describes the person's experience with abusing alcohol or other drugs.

Injection Drug Use. Enter the letter that best describes the person's experience with injecting drugs.

Needle Sharing. Enter the letter that best describes the person's experience with injecting drugs and sharing needles, syringes, or "works."

HIV Test. Enter the letter that best describes the person's experience with being tested for HIV.

GRADE COMPLETED. Enter the number of the highest school grade level that the person has completed. Enter "88" if the person is getting a GED. Enter "99" if the person has a GED.

REFERRALS MADE TO THESE SERVICES. For each of the services listed, write in an "I," an "O," or a "B" if you made a referral to that service. Enter an "I" if a referral was made to services within your agency ("I" stands for Inside). Enter an "O" if a referral was made to services outside your agency ("O" stands for Outside). Enter a "B" if a referral was made to services both inside and outside of your agency ("B" stands for Both). For example, if you referred the person to another agency for HIV testing you would enter an "O" in the box to the left of the label "HIV Testing."

HIV Testing. Enter an "I," an "O," or a "B" if you made a referral for HIV testing.

STD Clinic. Enter an "I," an "O," or a "B" if you made a referral to an STD clinic.

Medical Services. Enter an "I," an "O," or a "B" if you made a referral for medical services. This may include general health services as well as medical services that are specifically HIV-related.

Social Services. Enter an "I," an "O," or a "B" if you made a referral to a social service agency.

Food/Drop-In Center. Enter an "I," an "O," or a "B" if you made a referral to a drop-in shelter, food bank, or similar resource.

Shelter/Housing. Enter an "I," an "O," or a "B" if you made a referral to a shelter.

Educational/Voc. Training. Enter an "I," an "O," or a "B" if you made a referral to educational or vocational services.

Self-Help Group(s). Enter an "I," an "O," or a "B" if you made a referral to self-help groups (including 12-step and other support groups).

Case Manager. Enter an "I," an "O," or a "B" if you made a referral to a case manager.

Mental Health. Enter an "I," an "O," or a "B" if you made a referral for mental health services.

Substance Abuse. Enter an "I," an "O," or a "B" if you made a referral to a substance abuse program (inpatient or outpatient).

Family Planning. Enter an "I," an "O," or a "B" if you made a referral to a family planning clinic or other agency providing family planning services.

FOR CASUAL CONTACTS ONLY

If you contact a person or a group of people who decide not to participate in the outreach program, fill out a contact form for each of these "casual contacts." The person(s) may not want to give you any personal information, including their initials, birth date, or any information about their lifestyle or risk behaviors. For casual contacts, use this contact form, but only complete the following information:

PROVIDER. Enter the code for the provider doing the contact. The provider codes are on a separate sheet.

SERVICE DATE. Enter the numbers representing today's date (the date of the contact) in these boxes. Enter the month as a number from 01 to 12 for January through December. Enter the day as a two-digit number (01 to 31). Enter the last two digits of the current year (for example, "94" for 1994). Make sure that if a month or day is less than 10, you place a "0" before the number.

HOUR. Enter the hour in which the contact took place in these boxes. Use a "0" as a place holder if you use a number less than 10. Then darken the circle to indicate AM or PM. For example, if the contact occurred at 1:30 in the afternoon, enter "01" for Hour and darken the circle next to "PM." Do not enter the time in military or 24-hour format (such as 13).

LENGTH MINUTES. Enter the number of minutes that the contact lasted in these three boxes. If the contact lasted less than 100 minutes, enter a "0" before the number of minutes. For example, if the contact lasted 25 minutes, you would enter "025" and if it lasted 5 minutes you would enter "005."

GENDER. Darken the circle next to "Male" or "Female" to indicate the person's gender.

CLIENT BIRTHDATE/AGE. Where the boxes specify, enter the numbers representing the person's birth date. Enter the month as a number from 01 to 12 for January through December. Enter the day as a two-digit number (01 to 31). Enter the last two digits of the birth year (for example, "70" for 1970). Make sure that if a month or day is less than 10, you place a "0" before the number. If the person does not want to tell you his/her birth date, leave these boxes blank. If you do not know the person’s birthdate, fill in his/her age in the boxes labeled "Month/Age" and leave the "Day" and "Year" boxes blank. Estimate the age if the person does not tell you him or herself. If at all possible, you should try to enter the birthdate if you are using the TMG unique identifier.

REASON FOR CONTACT FORM. Darken the circle next to the type of contact that describes this activity. Fill in the circles for all that apply (see detailed description above).

RACIAL/ETHNIC IDENTITY. Darken the circle for the category that best describes the person's ethnic/racial background. If the person is multi-racial, you may darken more than one circle. Darken the circle next to "Don't Know" if you cannot tell the person's racial or ethnic identity.

CONTACT LOCATION. Darken the circle next to the place where the contact occurred. If it was not on the street, at a CBO, at a shelter or drop-in, at a clinic, at a hospital, or on the telephone, enter a brief description of the place in the boxes next to "Other." Darken only one circle to indicate the contact location (see detailed description above).

For a casual contact, you probably won't know the rest of the information requested on the contact form. However, if you know other information, please indicate it on the appropriate place on the contact form.

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