TOOL 7.

Short Encounter Form

Service Delivery Provider Number: __________________ ___________________________ Type of Site: ____________ Sub-National Area:

Codes ate of Contact &um'er Gender codes: Test codes: encounte #ith %ro$ided Unique Identification Code r # =TeSer$ice M= Male t offered and accepted (UIC) mm!dd!" %ro$ide F=Female $ = Te t offered and refu ed " r applicable becau e TG-MTF = Tran !endered " male to %= Te t not ate of female te ted po itive .irth TG-FTM =Tran !endered -- female to &= Te t not offered mm!dd!" male " Gender Fir t ever( Fir t ince )an#( *ubricant +ondom ,-+ First / (etters of mother0s name First / (etters of father0s name

&um'er of %artners in (ast 7 u da"s er already Male Female

Test and Treatment %ro$ided Treatment codes: (insert code in each 'o)) # = Treatment provided $= 'eferred for Treatment %= Treatment not provided and u er not referred HIV HEP HEP STI TB Of those times- ho# man" #ith condom+

Last time se) * used condom+

Times se) in the ,ast 7 da"s

B
Test Treatment Test Treatment

C
Test Treatment Test Treatment Test Treatment

F 4e s 333!333!33 3 3333 3333 333!33!333 4e s 333!333!33 3 3333 3333 333!33!333 4e s 333!333!33 3 3333 3333 333!33!333 &o 4e s &o 333 333 333 333 333 &o 4e s &o 333 333 333 333 333 &o 4e s &o 333 333 333 333 333 4es &o 333 333

TG2 1TF TG2 FT1 1 F TG2 1TF TG2 FT1 1 F TG2 1TF TG2 FT1

4es &o 333 333

4es &o 333 333

Instructions for the Short Encounter Form

'ef code Sub-indicator Definition ,ndicator Unique Identification code An e.ample of t/e uni0ue identifier code developed by Population Service ,nternational i a imple 1-di!it code compo ed of: Fir t t2o letter of mot/er3 fir t name Fir t t2o letter of fat/er3 fir t name Gender 4ear of birt/ 5la t t2o di!it 67 Gender M Male F Female TG-MTF Tran !endered " male to female TG-FTM Tran !endered " female to male ate of .irth ,nput t2o di!it for mont/8 t2o di!it for day8 and t2o di!it for year First / (etters of mother0s ,nput fir t t2o letter of mot/er3 name name First / (etters of father0s ,nput fir t t2o letter of fat/er3 name name ate of encounter ,nput t2o di!it for mont/8 t2o di!it for day8 and t2o di!it for year Contact #ith Ser$ice %ro$ider Fir t ever( +ircle 4e if t/i i t/e per on3 fir t vi it to t/i ite7 +ircle No if t/e per on /a vi ited t/e ite before Fir t ince +ircle 4e if t/i i t/e per on3 fir t vi it ince t/e be!innin! of t/e year7 +ircle No )an #( if t/e per on /a vi ited t/e ite at lea t once already t/i year &um'er %ro$ided +ondom,nput t/e number of condom-compatible lubricant provided durin! t/i compatible encounter7 ,f no lubricant 2ere provided8 input 97 lubricant +ondom ,nput t/e number of condom provided durin! t/i encounter7 ,f no condom 2ere provided8 input 97 ,-+ ,-+ material con i t of pamp/let 8 flyer 8 or ot/er information8 education and communication material 7 ,f no ,-+ material 2ere provided to t/e per on durin! t/i encounter8 input 97 ,f ,-+ material 2ere provided to t/e per on today8 input t/e number of material provided &um'er of %artners in %ast Male :rite in t/e number of male and;or female e.ual partner t/e per on /a /ad in 7 a"s t/e pa t 1 day 7 ,f t/e per on /a not /ad any e.ual partner in t/e la t 1 day 8 Female input 9 and <ip ot/er 0ue tion related to e.ual act Last time se) 2used +ircle 4e if t/e per on u ed a condom t/e la t time /e en!a!ed in a e.ual act7 condom+ +ircle No if /e did not u e a condom t/e la t time /e en!a!ed in a e.ual act7 ,f neit/er 4 nor N i circled8 it mean t/at t/e per on refu ed to an 2er8 doe not <no28 or t/e data i mi in!7 Times Se) in %ast 7 da"s :rite in t/e number of time t/e per on /a en!a!ed in a e.ual act in t/e pa t 1 day 7 ,f t/e an 2er i 98 <ip t/e ne.t 0ue tion7 Of those times- ho# man" ,f t/e per on en!a!ed in a e.ual act in t/e la t 1 day 8 a < /o2 many time a #ith condom+ condom 2a u ed7 :rite t/e number in t/e bo.7 Test and Treatment %ro$ided (insert code in each 'o)) Test # Te t offered and accepted ,nput # in t/e Te t bo. if a te t 2a offered to t/e per on and /e a!reed to be