TOOL 10 Short Encounter Form

Service Delivery Provider Number: ______Type of Site: ______Sub-National Area: ______

Unique Identification Code (UIC) / Date of encounter
mm/dd/yy / Contact with Service Provider / Number Provided / Number of Partners in last 7 days / Last time sex – used
condom? / Times sex in the past 7 days / Of those times, how many with condom? / Test and Treatment Provided
(insert code in each box)
Gender / Date of Birth
mm/dd/yy / First 2 letters of mother’s name / First 2 letters of father’s name / First ever? / First since Jan1? / Lubricants / Condoms / IEC / Male / Female / HIV / HEPB / HEPC / STI / TB
Test / Treatment / Test / Treatment / Test / Treatment / Test / Treatment / Test / Treatment
M F
TG-MTF
TG-FTM / ___/___/___ / ____ / ____ / ___/__/___ / Yes No / Yes No / ___ / ___ / ___ / ___ / ___ / Yes
No / ___ / ___
M F
TG-MTF
TG-FTM / ___/___/___ / ____ / ____ / ___/__/___ / Yes No / Yes No / ___ / ___ / ___ / ___ / ___ / Yes
No / ___ / ___
M F
TG-MTF
TG-FTM / ___/___/___ / ____ / ____ / ___/__/___ / Yes No / Yes No / ___ / ___ / ___ / ___ / ___ / Yes
No / ___ / ___
Codes
Gender codes: / Test codes: / Treatment codes:
M= Male
F=Female
TG-MTF = Transgendered – male to female
TG-FTM =Transgendered -- female to male / 1 =Test offered and accepted
2 = Test offered and refused
3= Test not applicable because useralready tested positive
4= Test not offered / 1 = Treatment provided
2= Referred for Treatment
3= Treatment not provided and usernot referred

Instructions for the Short Encounter Form

Ref code
Indicator / Sub-indicators / Definition
Unique Identification code
An example of the unique identifier code developed by Population Services International is a simple 7-digit code composed of:
  • First two letters of mother’s first name
  • First two letters of father’s first name
  • Gender
  • Year of birth (last two digits).

Gender
M / Male
F / Female
TG-MTF / Transgendered – male to female
TG-FTM / Transgendered – female to male
Date of Birth / Input two digits for month, two digits for day, and two digits for year
First 2 letters of mother’s name / Input first two letters of mother’s name
First 2 letters of father’s name / Input first two letters of father’s name
Date of encounter / Input two digits for month, two digits for day, and two digits for year
Contact with Service Provider
First ever? / Circle Yes if this is the person’s first visit to this site. Circle No if the person has visited the site before
First since Jan 1? / Circle Yes if this is the person’s first visit since the beginning of the year. Circle No if the person has visited the site at least once already this year
Number Provided
Condom-compatible lubricants / Input the number of condom-compatible lubricants provided during this encounter. If no lubricants were provided, input 0.
Condoms / Input the number of condoms provided during this encounter. If no condoms were provided, input 0.
IEC / IEC materials consist of pamphlets, flyers, or other information, education and communication materials. If no IEC materials were provided to the person during this encounter, input 0. If IEC materials were provided to the person today, input the number of materials provided
Number of Partners in Past 7 Days / Male / Write in the number of male and/or female sexual partners the person has had in the past 7 days. If the person has not had any sexual partners in the last 7 days, input 0 and skip other questions related to sexual acts
Female
Last time sex -used condom? / Circle Yes if the person used a condom the last time he engaged in a sexual act. Circle No if he did not use a condom the last time he engaged in a sexual act. If neither Y nor N is circled, it means that the person refused to answer, does not know, or the data is missing.
Times Sex in Past 7 days / Write in the number of times the person has engaged in a sexual act in the past 7 days. If the answer is 0, skip the next question.
Of those times, how many with condom? / If the person engaged in a sexual act in the last 7 days, ask how many times a condom was used. Write the number in the box.
Test and Treatment Provided (insert code in each box)
Test codes / 1 / Test offered and accepted / Input 1 in the Test box if a test was offered to the person and he agreed to be tested.
2 / Test offered and refused / Input 2 in the Test box if a test was offered to the person and he refused to be tested.
3 / Test not applicable because useralready tested positive / Input 3 in the Test box if a test was not applicable because the person is positive for the outcome in question. For example, if the person is HIV positive, he will not be offered an HIV test unless he wants to be tested for verification purposes.
4 / Test not offered / Input 4 in the Test box if the test was not offered. Reasons for this include test stockouts, person who does the testing or the counselling is unavailable, etc.
Treatment codes / 1 / Treatment provided / Input 1 in the Treatment box if treatment to the person during this encounter.
2 / Referred for treatment / Input 2 in the Treatment box if the person was referred to another site for treatment.
3 / Treatment not provided and usernot referred / Input 3 if the person was not given treatment and was not referred for treatment. Use this code if the site normally provides treatment to users, but currently has a stockout of medicine. Also use this code if the person is not eligible for treatment (e.g. person’s CD4 count has not yet reached the level at which treatment is recommended).