Microsoft word - hivqual_u_paper_abstract_form_v4
HIVQUAL-U Manual Data Collection Form (version 4)
Start Date: XX/ XX/ XXXX
End Date: XX/XX/XXXX
Patient Data Entry Screen 1: “Monitoring HIV Status and Continuity of Care”
Did the patient have any CD4 counts during the review period?
• If no, go to 1.1.2
(If yes in 1.1
) Record CD4 counts from tests during the review period only:
(If No in 1.1
) Are Total lymphocyte counts available for this patient during review period?
• If yes, go to 188.8.131.52,
• if no or “not stated”, go to 1.2
(If yes in 1.1
) Record TLC results from tests during the review period only:
Did the patient visit for medical care in the past 6 months?
Record visit dates and WHO Clinical staging at each visit in the past 12 months:
Patient Data Entry Screen 2: Prevention Education and Prophylaxis
Was HIV prevention discussed in the last 3 months?
Prevention education includes talks on
Abstinence, Faithfulness, Condom use
VCT – Child’s blood tests and Testing partners
. Was cotrimoxazole prescribed to the patient in the last 6 months?
Patient Data Entry Screen 3: “Anti-retroviral Therapy and Adherence”
Was the patient on ARV therapy (other than PMTCT) during the review period?
• If yes, go to 3.1.1
• If no or “not stated,”, stop
Is the patient still on ARV therapy at the end of the review period?
Report all ARV regimens received during the review period, with starting date and ending
date (if applicable). Each line should include a complete regimen (not just a new single drug). Do not include ARV taken solely to prevent mother-to-child transmission of HIV. Select drug regimens or individual drugs from the pop-up menu
(AZT+3TC), also known as Zarlivir
Saquinavir, Invirase, Fortovase
Lamivudine, Lamivir, Epivir
Tenofovir, Viread (used in clinical boosted Lopinavir
Specified other drug
3.2. Was patient adherence to ARV therapy assessed in the last 2 quarters during the review period?
• If no or “not stated,” go to 4.1
3.3. What was the score at the last adherence assessment in the review period?
Patient Data Entry Screen 4: “TB”
4.1 Was the patient assessed for clinical symptoms or risk factor for TB during the review period?
• If yes go to 4.1.1
Contact with individuals with active TB
4.1.1 (If yes)
was the patient screened for TB?
184.108.40.206 Was the patient screened by chest x-ray?
4. 1.1.2 Was the patient screened by sputum AFB?
4. 1.1.3 Did the patient diagnosed TB disease?
4.2 Was the patient treated for active TB?
PATIENT ASSESSMENT FORM Malaria Prophylaxis Patient name ______________________________________________Name of GP (optional) _______________________________________Address ___________________________________________________Name & address of surgery (optional) _____________________________________________________________________________________________________________________________
MATERIAL SAFETY DATA SHEET 1. IDENTIFICATION OF MATERIAL AND SUPPLIER PRODUCT NAME: Barmac Permethrin D INSECTICIDAL GROUP: Group 3A APVMA REGISTRATION NUMBER : 49084 AUSTRALIAN DISTRIBUTOR: USE : Insecticide EMERGENCY PHONE NUMBERS: Fire Brigade, Ambulance and Police Services: 000 FORM: Dust 2. HAZARD IDENTIFICATION Classified as hazardous according to the