Peer Advocate Activity Form

Date: ____/______Peer Advocate Name: ______Advocate ID: ______

(mo / year)

Location: ______Location ID: ______

/ Age / Gender / Ethnicity / Race
(Check all that apply) / HIV Risk / HIV Status / Activities, Notes, and Details /
/ A. 12 or below
B. 13–18
C. 19–24
D. 25–34
E. 35–44
F. 45 and over / Female
Male
Transgender (MTF)
Transgender
(FTM) / H/L: Hispanic /Latino/a
NH/L: Non Hispanic /Latino/a / A. American Indian/Alaska Native
B. Asian
C. Black/African American
D. Native Hawaiian/Pacific Islander
E. White / A. MSM
B. MSM/IDU
C. IDU
D. Heterosexual at risk
E. Sex involving transgender
F. Other/Risk not identified / + HIV+
- HIV –
DK: Don’t Know
R: Refused
NA: Not Asked / For Example:
· “Positive Living” story distributed
· Discussion of HIV/AIDS transmission
· 5 condoms distributed
· CTR referral made /
1 / A B C D E F / F M MTF FTM / H/L NH/L / A B C D E / A B C D E F / + - DK R NA
2 / A B C D E F / F M MTF FTM / H/L NH/L / A B C D E / A B C D E F / + - DK R NA
3 / A B C D E F / F M MTF FTM / H/L NH/L / A B C D E / A B C D E F / + - DK R NA
4 / A B C D E F / F M MTF FTM / H/L NH/L / A B C D E / A B C D E F / + - DK R NA
5 / A B C D E F / F M MTF FTM / H/L NH/L / A B C D E / A B C D E F / + - DK R NA
6 / A B C D E F / F M MTF FTM / H/L NH/L / A B C D E / A B C D E F / + - DK R NA
7 / A B C D E F / F M MTF FTM / H/L NH/L / A B C D E / A B C D E F / + - DK R NA
8 / A B C D E F / F M MTF FTM / H/L NH/L / A B C D E / A B C D E F / + - DK R NA
9 / A B C D E F / F M MTF FTM / H/L NH/L / A B C D E / A B C D E F / + - DK R NA
10 / A B C D E F / F M MTF FTM / H/L NH/L / A B C D E / A B C D E F / + - DK R NA
11 / A B C D E F / F M MTF FTM / H/L NH/L / A B C D E / A B C D E F / + - DK R NA
12 / A B C D E F / F M MTF FTM / H/L NH/L / A B C D E / A B C D E F / + - DK R NA
13 / A B C D E F / F M MTF FTM / H/L NH/L / A B C D E / A B C D E F / + - DK R NA
14 / A B C D E F / F M MTF FTM / H/L NH/L / A B C D E / A B C D E F / + - DK R NA
15 / A B C D E F / F M MTF FTM / H/L NH/L / A B C D E / A B C D E F / + - DK R NA

1. Discuss things that made your encounters easy:

2. Discuss challenges you faced during this outreach event and what we can do to help overcome the challenge: