Reasons for screening

([1 - Walk-in/General consultation; 2 - Community outreach;

Current Age Sex at Birth 3 - Prenatal care; 4 - Pre-employment; 5 - STI screening; 6 -
Pre-treatment initiation for HIV; 7 - Hemodialysis; 8 -
Blood/organ donation; 9 - Others (please indicate)]

26 M Pre-employment
35 M Pre-employment
48 M Pre-employment
17 F Prenatal care
22 F Pre-employment
M Pre-employment
M Pre-employment
M Pre-employment
M Pre-employment
M Pre-employment
F Pre-employment
18 F Prenatal care
36 F Prenatal care
31 F Prenatal care
F Prenatal care
24 F Pre-employment
17 F Prenatal care
23 F Prenatal care
M Pre-employment
F Pre-employment
F Pre-employment
53 M Pre-employment
22 F Prenatal care
27 F Prenatal care
27 F Prenatal care
26 F Prenatal care
F Pre-employment
27 F Prenatal care
F Pre-employment
17 F Prenatal care
F Pre-employment
F Walk-in/General Consultation
F Walk-in/General Consultation
F Walk-in/General Consultation
F Walk-in/General Consultation
M Walk-in/General Consultation
M Walk-in/General Consultation
F Walk-in/General Consultation
F Walk-in/General Consultation
F Walk-in/General Consultation
F Walk-in/General Consultation
F Walk-in/General Consultation
40 F Walk-in/General Consultation
56 M Walk-in/General Consultation
76 F Walk-in/General Consultation
77 F Walk-in/General Consultation
68 F Walk-in/General Consultation
74 F Walk-in/General Consultation
66 F Walk-in/General Consultation
87 M Walk-in/General Consultation
56 F Walk-in/General Consultation
62 M Walk-in/General Consultation
58 F Walk-in/General Consultation
68 F Walk-in/General Consultation
F Prenatal care
F Prenatal care
F Prenatal care
F Walk-in/General Consultation
F Walk-in/General Consultation
F Walk-in/General Consultation
F Walk-in/General Consultation
M Walk-in/General Consultation
M Walk-in/General Consultation
F Walk-in/General Consultation
M Walk-in/General Consultation
 F Walk-in/General Consultation
F Walk-in/General Consultation
F Walk-in/General Consultation
M Walk-in/General Consultation
M Walk-in/General Consultation
M Walk-in/General Consultation
M Walk-in/General Consultation
F Walk-in/General Consultation
F Walk-in/General Consultation
M Walk-in/General Consultation
M Walk-in/General Consultation
44 F Walk-in/General Consultation
30 F Walk-in/General Consultation
45 F Walk-in/General Consultation
54 F Walk-in/General Consultation
60 F Walk-in/General Consultation
68 F Walk-in/General Consultation
63 F Walk-in/General Consultation
48 M Walk-in/General Consultation
47 F Walk-in/General Consultation
76 F Walk-in/General Consultation
51 F Walk-in/General Consultation
74 M Walk-in/General Consultation
 VIRAL HEPATITIS B MASTERLIST
CASE REPORT FORM CARE FORM

Date of specimen referral Date when confirmatory *Date of linkage to care

Date of Consult Was the patient Current Pregnant CBC with for HBV confirmatory test test result is released to Result of HBV DNA (patients who have confirmatory test and other *Was consent to Treatment Eligibility Date of Enrollment to Date of Last Refill # of pills Expected Date of Refill / Return Date of HBV DNA test after HBV DNA Result
Patient no. (mm/dd/yyyy) referred to the UIC First Name Middle Name Last Name Age Sex at Birth Status Date of positive HBsAg test AST ALT Platelet Creatinine HBV DNA (mm/dd/yyyy) facility confirmatory test baseline laboratory tests and had at least 1 participate in the Treatment Antiviral Regimen (mm/dd/yyyy) dispensed (mm/dd/yyyy) Treatment Status treatment initiation (copies/mL) Treatment Outcome Remarks
facility? (if female) (mm/dd/yyyy) consultation with a healthcare provider about research obtained? (mm/dd/yyyy) (mm/dd/yyyy)
treatment eligibility)
 Reasons for screening
[1 - Walk-in/General consultation; 2 - Community
Current Age Sex at Birth outreach; 3 - Prenatal care; 4 - Pre-employment; 5 - STI
screening; 6 - Pre-treatment initiation for HIV; 7 -
Hemodialysis; 8 - Blood/organ donation; 9 - Others (please
indicate)]
 VIRAL HEPATITIS C MASTERLIST
CASE REPORT FORM CARE FORM

*Date of linkage to care

Date of Consult Was the patient Date of Birth Current Pregnant Date of positive anti-HCV test CBC with Date of specimen referral Date whenisconfirmatory (patients who have confirmatory test and *Was consent to Date of HCV RNA test after
Patient no. (mm/dd/yyyy) referred to the UIC First Name Middle Name Last Name (mm/dd/yyyy) Age Sex at Birth Status (mm/dd/yyyy) AST ALT platelet Creatinine HCV RNA for HCV confirmatory test test result released to
facility
Result of HCV RNA
confirmatory test other baseline laboratory tests and had at participate in the Treatment Eligibility Date of Enrollment
(mm/dd/yyyy) Antiviral Regimen Date of Last Refill
(mm/dd/yyyy)
# of pills
dispensed
Expected Date of Refill / Return
(mm/dd/yyyy) *Treatment status *Assessed for cure treatment initiation HCV RNA test result
(copies/mL) Treatment Outcome Remarks
facility? (if female) (mm/dd/yyyy) (mm/dd/yyyy) least 1 consultation with a healthcare research obtained? (mm/dd/yyyy)
provider about treatment eligibility)

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