88-1332 WHITE - CITV CLERK
PINK - FINANCE G�I TY OF SA I NT PAU L Council
CANARV - DEPARTMENT File NO• ��_����
BLUE - MAVOR
Counci esolution --���
` ` • �� ?��� �
Presented By
Referred To Committee: Date
Out of Committee By Date
RESO�VED, that the proper City Officials are hereby authorized and directed to
execute a contract with the State of Minnesota, Minnesota Department of Health;
WHEREBY, the City shal l provi de ri sk reduction and di sease prevention education
and counseling, antibody testing and referral service to persons at increased
risk of exposure to the human immunodeficiency virus (HIV) , the causative agent
of Acquired Immunodeficiency Syndrome (AIDS) . The services are to be provided
through the Saint Paul Family Planning Program according to the terms of said
contract, a copy of which is kept on file and on record in the Department of
Finance and Management Services.
COUNCIL MEMBERS
Yeas Nays Requested by Department of:
Dimond
��v [n Favor
Goswitz �—
�be1�j � Against BY �
Sonnen
Wilson
AU�'j � � .'� Form Ap e by City At rne
Adopted hy Council: Date �
c
Certified Passed u cil c et y BY
g�.
A►pproved by avor�, D � �uu i � � Approved by Mayor for S is '+n to Council
By �"`�v BY
Rl�?PS�iEB !;!;� ? �� ��g�
�-/33�,
N°_: �13676 �
G�ma�uL7.ty Servioes DEPARTMENT . - - - -- - —
, MarY SOrin£n CONTACT NAt�E ` , �:;
. �E �
�99_7735 PHONE
�L�1�-_?_f;; ;a 9f3f3 :DATE
ASSIGi� pi31�8ER F08 ROUTING ORDER: (See reverse side.)
��t I��
.,,]� Department Director ' 3 Mapor (or Assistant)
_ Finsnce and l�tanagement Services Director 4 City Glerk RECEIVE�,
:Budget Director ,
City Attorney _ �
G A 5 (Clip all locatioas for signature.)
C0��
�IAT WILL BE ACSIEVED B�t TAKING ACTION ON TfIE ATTAC�iBD 1�lATF.it?ALS? (Purpose/Rationale)
�
�_Re�olution to allaw City sic�natures on an agresnent bebw+een the City of Saint Paul and the
Mitn�so�ta D�x�nt of Hea].th. Ui�der the tenns of the c�ontract the Div3.sion of pub�;ic Health
will prpvide risk reduction and disease p�revention edi�cation arid vo�e7.ixuJ. �'��X--�t�J
ar�d referral servic�es to persons at increased ri.sks of exp�sure tc� AcxXui.red Iamnauu�eficiency
SYndx'ane (�DS) -
CQST/BENEFIT. BUDGETARY. AND PERSONNEL IMPACTS ANTICIPATED:
F'tn�d will be reaeived for the Minnesota Deaprtment of Health_for the vocitract pericad frcm
July 1, 1988 to June 30, 1989. Zbta.l a¢rount of oontraat $16,240. No p�sso�mmel i�a�ets are ���
anticipat�ed.
RECEIVED
JUL. 2 91�r�8
FINANCING SOURCE AI�D BUDGET ACTIVITY NUMBER CHARGED OR CRLDITED:
(M$yor's signature not required if under $10,000.) MAYOf�°S ��r•�cE
Total Aa�unt of Trans�ctian: $16,240 Activity Number: 33233
Fwza�g sour�s: ru,r,nesota �ar�n�ent of xealtt� Council Research
Center,
�TTACHMENT3: (List and number all attachments.� AUG 2 1988
1. �;.1 �1�� RECEIVED
�: �nmt -�-original and fo�ur �ies J U L u 8 1988
�`1 TY �1�"i't',��'J'��'`�;
A,,�11�IINISTRATIVE PR�CEDURES
j
_Yes _No Rules, Reguiations, Procedures, or Budget A�endment required?
_Yes _No If yes, are they or timetable attached?
DEPARTMENT REVIEW CITY ATTORNEY REVIEW
�
, Yes �_No Council rasolution required? Resoiution required? �Yes _No �
_Yes _No Insuratice required? Insurance sufficient? _Yes _No�
Yes _No Insurance .attached?
� �� -/,.3 ,3�
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el e
�
STATE OF MINNESOTA
� GRANT CONTRACT
THIS GRANT CONTRACT, which shall be �interpreted pursuant to the laws of the
State of Minnesota between the State of Minnesota, acting through its
Minnesota Department of Health (hereinafter STATE)
And: City of St. Paul, Acting through its Division of Public Health
Address: 555 Cedar St., St. Paul , Minnesota 55101 �
Soc. Sec. or MN Tax ID No. : N/A
Federal Employer ID No. (if applicable): 1-416005521-AI
(NOTICE T0 6RANTEE. You are required by Minnesota Statutes, Section 270.66,
to provide your social security number or Minnesota Tax identificatian number
if you do business with the State of Minnesota. This information may be used
in the enforcement of federal and state tax laws. Supplying these nnmbers
could result in action to require you to file state tax returns and
delinquent state tax liabilities. THIS GRANT CONTRACT WILL NOT BE APPROVED
UNLESS THESE NUMBERS ARE PROVIDEO. These numbers will be available to federal
and state tax authorities and state personnel involved in the payment of state
obligations). - .
(hereinafter GRANTEE), witnesseth that: .
WHEREAS, the STATE, pursuant to Minnesota Statutes 144.05 B is empowered to
provide for the organization of services for prevention and contral of disease
and limitation of disabilities resulting therefrom
AND WHEREAS, GRANTEE represents that it is duly qualified and willing to
perform the duties set forth herein, NOW THEREFORE, it is agreed:
I. GRANTEE'S DUTIES. GRANTEE, who is not a state emplayee, shall for a
period beginning July 1, 1988 and ending June 30, 1989, provide risk
reduction and disease prevention education and counseling, antibody
testing, and referral services to persons at increased risk of exposure
to the human immunodeficiency virus (HIV), the causative agent of
acquired immunodeficiency syndrome (AIOS). These duties include, but
are not limited to the following:
A. Provide each client with a copy of the AIDS Risk Assessment
form, (see Attachment A), developed by the Minneapolis Health
Department. Clients will be instructed to complete this self-
administrated assessment tool and return form to the
counselor/clinician. Clients who answer yes or unsure to
questions 12-14, 19-27, or report multiple sex partners will
then receive individual counseling in response to their
answers. The counselor/c�inician will recommend the fotlowing
clients receive the HIV antibody test: .
1) men who have had sex with another man since I977; 2) persons
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who have intravenously self-administered illicit drugs or
chemicals since 1917; 3) persons with clinical or laboratary
evidence of HIV infection, such as those with signs or symptoms
compatible with AIDS or AIDS-related complex; 4) persons born
in countries where heterosexual transmission is thought to play
a major role (e.g. , Haiti, Central African countries); 5j male
or female prostitutes and their sex partners; 6) sex partners
of HIV infected persons or persons at increased risk; 7) all
persons with hemophilia who have received clotting-factor
products and 8) persons who have had 4 or more sex partners in
the past 12 months. �
In the program referred to in Clause I, the GRANTEE sha11:
1. Provide qualified personnel who are specifically trained in
counseling persons about HIV risk reduction, disease
prevention, and notification and referral of sexual and
needlesharing partners. Provide documentation to STATE of
training which has been completed or is to be completed, for
approvaT on all personnel providing the aforementioned
services.
2. Counsel each person before providing HIV antibody testing and
include:
' a. individualized assessment of risk of exposure to HIV; and
b. information about the nature and meaning of the test and
- its results for the individual ; and
c. risk-reduction and disease prevention recommendations
specific to the person's risk of exposure to HIV; and
� d. the need to notify sexual and/or needlesharing partners
if the HIV antibody test is positive.
3. Provide HIV serologic testing of serum specimens collected
from person at increased risk of exposure to HIV and submit
specimens only to qualified laboratories approved by the
STATE.
4. Use written materials such as posters, literature and
pamphlets as determined by the GRANTEE to inform and educate
person at increased risk of exposure to HIV.
5. Counsel each person .after HIV antibody test results have been
provided to the persan, and include:
a. assessment of the person's emotional response to the test
results; and
b. information about the meaning of the test result for the
person; and
c. risk reduction and disease prevention recommendations
specific to the person's risk of exposure to HIV.
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6. Assure that each HIV seropositive person receives referrals
for medical evaluation and psychosocial support.
7. Assure that each HIV seropositive female receives a -referral
for contraceptive couhseling.
8. Counsel each HIV seropasitive person about notifying and
referring their sexual and/or needlesharing part�ers for the
purpose of HIV risk reduction and disease prevention
counseling and antibody testing. �
B. Conduct educational and informational activities which wi11 enhance
the level of participation in this program� of persons at increased
risk of exposure to HIV.
C. Provide the services described in Section I. , A-B, at times that
are reasonably convenient for the majority of people in the risk
groups in Section I, A. (above).
D. Assure the confidentiality of all patient records and records of
test results.
E. Collect statistical and other summary -data on persans seeking the
HIV antibody test using forms provided by the STATE. (See
Attachment B) .
F. Provide the services described in this contract at no charge to any
person requesting them.
. G. Report HIV seropositives to the AIDS Epidemiology Unit at MDtf using
reporting cards provided by the State.
II. CONSID�RATION AND TERMS OF PAYMENT.
� A. CONSIDERATION for all services performed and goods or materials
supplied by GRANTEE pursuant to this grant contract shall be paid
for the STATE as follows:
1. The total obligation of the STATE for all compensation and
� reimbursements to GRANTEE shall not exceed sixteen thoasand
two hundred and forty dollars (a16,240.00} .
2. Reimbursement for travel and subsistence expenses actuaTly and
necessarily incurred by GRANTEE'S performance of the grant
contract in an amount not to exceed zero dollars (a0.00) ;
provided, that GRANTEE shall be reimbursed for travel and
subsistence expenses in the same manner and in no greater
amount than provided in the current "Commissioner's P1an"
promulgated by the Commissioner of Employee Relatians.
GRANTEE shall not be reimbursed for travel and subsistence
expenses incurred outside the State of Minnesota unless it has
received prior written approval for such out-of-state travel
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from the STATE.
3. Compensation shall be consistent with the Pragram Line Item
Budget below. GRANTEE shall not seek, nor shall the STATE
pay, compensation to GRANTEE for any indirect, overhead or
administrative costs. not otherwise inCluded as an expense
within the Program line Item Budget.
Proaram .ne �tgQ Budaet
The GRANTEE sfiall adhere to the following program budget in
performing the activities listed in Clause I, GRANTEE'S
DUTIES:
Categorv of Exnenditure Estimated A1location
1. COUNSELING SERVICES S 12,500.00
500 persons @a25.00/person
2. TESTING SERVICES . a 3,740.00
500 screening tests @57.00/test:E3,500.00
16 confirmatory tests @ E15.OQ/test:�240.00
TOTAL . S I6,240.00
Modifications within each category of the above line item
budget of less than 10 percent of any line item are permitted
without prior approval by the STATE, so long as notification
of such modifications is made through the sabmitted monthly
� expenditure reports. Provided, however, that the total
obligation of the STATE for all compensation and
reimbursements to GRANTEE shall not exceed sixteen thousand
two hundred and forty dollars (�16,240.00) .
B. TERMS OF PAYMENT
1 . The STATE will reimburse for counseling and testi�g of persons
who have been identified as at risk and checked off in any box
27-39 on this form, or who have four or more listed under
boxes 58-60 for numbers of sex partners in the Iast I2 months
(See Attachment B).
2. Receive the rate of reimbursement of twenty-five dollars
(�25.00) for each person who is tested and who receives
counseling. ,
3. Receive reimbursement for the actual cost of HIV serologic
test, not to exceed rates as shown in (a) and (b) below, for
- each person who is identified as being at increased risk of
exposure to HIV, and who receives counseling concerning
reducing their risk of exposure, disease prevention, and
prevention of disease among others. GRANTEE sha11 not exceed
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..,.,.�..,_.._�_____ ,'.-,..�.-.-.,�,�._....�.. -�_�:._-----...-.
0 o i ,� ,��
these amounts without the prior written consent of the STATE's
authori2ed agent for this contract.
a. Seven dollars (�7.00j per HIV antibody screenirtg test
(EIA) performed.
b. Fifteen dollars (515.00) per confirmatory test (Western
blot) performed.
4. The. total reimbursement by the State. for screening and
confirmatory tests shall not exceed three thousand seven
hundred and forty dollars (53,740.00)� without the written
consent of the STATE's authorized agent for this contract.
6. 6RANTEE shall present invoices for services performed monthly, na
later than the twenty-fifth calendar day following the month of
invoice, reflecting only those services performed durinq the month
of the invoice.
C. Invoices for services performed shall be presented on forms provided
by the STATE according to the line item budget above. Form to be
used is presented in Exhibit A, attached hereto and made a part
hereof.
III. CONDITIONS OF PAYMENT. All services by GRANTEE pursuant to this grant
contract shall be performed to the satisfaction of the STATE, as
determined in the sole discretion of its authorized agent, and in
accord• with all applicable federal , state and local laws, ordinances,
rules and regulations. GRANTEE shall not receive payment for work
found by the STATE to be unsatisfactory, or performed in violation of
federal , state, or local law, ordinance, rule or regulation.
�IV. TERM OF GRANT CONTRACT. This grant contract shall be effective on
July 1, 1988, or upon such date as it is executed as to encumbrance by
the Commissioner of Finance, whichever occurs later, and shail remain
in effect until June 30, 1989, or until all obligations set forth in
this grant contract have been satisfactorily fulfilled, whichever
occurs first.
A. 6RANTEE shall have ninety (90) days immediately following the end
of the grant contract period to liquidate all unpaid obligations
related to the project incurred prior to the end of the grant
period and to submit a detailed accounting of these cumulative
expenditures to the STATE.
B. 6RANTEE will return to the STATE all funds provided by the STATE
which are not expended for allowable project costs within ninety
(90) days following the end of the grant contract period.
V. CANCELLATION
A. Upon GRANTEE'S substantial failure to comply with the provisions of
this grant contract, the STATE may terminate this grant contract
without prejudice to the right of the STATE to recover any money
previously paid. The termination shall be effective upon the STATE
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giving GRANTEE written notice at its last known address.
B. The STATE or GRANTEE may cancel this grant contract at any time,
with or without cause, upon sixty (60) days written notice to the
other party. In the event of such cancellation, GRRNTEE shall be
entitled to payment, determined on a pro rata basis, for services
satisfactorily performed.
C. Should this grant contract be terminated prior to the scheduled
date, GRANTEE shall refurrd to the STATE a11 remaining unexpended
grant contract monies within forty-five (45) days of the date of
effective terminatio�.
VI. STATE'S AUTHORIZED AGENT. The STATE'S authorized agent for the
purposes of administration of this grant contract is
� Mary K. Sheehan, Minnesota Oepartment of Health. Such agent shall have
that authority for acceptance of GRANTEE'S services and if such
services are accepted as satisfactory, shall so certify on each invoice
submitted pursuant to Clause II, paragraph B.
VII. ASSIGNMENT. GRANTEE shall neither assign nor transfer any rights or
obligations under this grant contract without the prior written consent
of the STATE. �
VIII. AMENDMENTS. Any amendments to this grant contract shall be in writing,
and shall be executed by the same parties who executed the original
grant contract or their successors in office. '
IX. LIABILITY. GRANTEE agrees to indemnify and save and hold the STATE,
its agents and employees harmless from any and all claims or causes of
action arising from the performance of this grant contract by GRANTEE
or GRANTEE'S agents or employees. This clause sha11 not be construed
to bar any legal remedies GRANTEE may have for the STATE'S failure ta
fulfill its obligations pursuant to this grant contract.
X. STATE AUDITS. The books, records, documents, and accounting
procedures, and practices of the GRANTEE relevant to this grant
contract shall be subject to examination by the STATE, the legislative
auditor, and the state auditor. Records shall be sufficient to reflect
all costs incurred in performance of this grant contract. GRANTEE will
comply with federal audit requirements pursuant to the Single Audit
Act of 1984 (P.L. 98-502) and Office of Management and Budget (OMB)
Circular A-128.
XI. OWNERSHiP OF DOCUMENTS. Any reports, studies, photographs, negatives,
or other documents prepared by GRANTEE in the performance of its
obligations under this grant contract shall be the exclusive property
of the STATE and all such materials shall be remitted to the STATE by
GRANTEE upon completion, termination or cancellation of this grant
contract. GRANTEE shall not use, willingly allow or cause to have such
materials used for any purpose other than performance of GRANTEE'S
obligations under this grant contract without the prior written cansent
of the STATE.
XII. AFFIRMATIVE ACTION. (When applicable) GRANTEE certifies that it has
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received a certificate of compliance from the Commissioner of Human
Rights pursuant to Minnesota Statutes, Section 363.073.
XIII. WORKER'S COMPENSATION. In accordance with the provisions of Minnesota
Statutes, Section 176.182, the GRANTEE has provided acceptable evidence
of compliance with the workers' compensation insurance coverage
requirement of Minnesota Statutes, Section 176.181, Subdivision 2.
XIV. ANTITRUST. GRANTEE hereby assigns to the State of Minnesota any and
all claims for overcharges as to goods and/or services provided in
connection with this grant contract resulting from antitrust violations
which arise under the antitrust laws of the United States and the
antitrust laws of the State of Minnesota.
XV. DATA PRACTICES. The GRANTEE shall agree to indemnify and save and hold �
the STATE, its agents and employees, harmless from any and all claims
or causes of action arising from a violation of any provisiort of
Minnesota Statutes 13.01-13.90.
XVI. VOTER REGISTRATION. (When applicablej GRANTEE sha11 provide
nonpartisan voter registration services and assistance, using forms
provided by the STATE, to employees of GRANTEE and the public as
required by Minnesota Statutes, 1987 Supplement, Section 201.162.
XVII. GRANTEE certifies that no funding provided under this grant contract
will be used to support religious counseling or partisan political
activity.
XVIII. OTHER PROVISIONS.
A. 6RANTEE agrees to utilize competitive bidding and other procedures
required by Federal , State, and local laws, ordinances, or
� regulations governing purchasing and fiscal procedures.
B. The STATE shall , during the course of this grant contract, evaluate
GRANTEE'S progress towards goals and objectives of the grant
contract and compliance with any special conditions. The STATE
reserves the right to request additional information from GRANTEE
to carry out its evaluation.
C. GRANTEE agrees to make all its financial records reTated to the
grant contract available to the STATE upon request during normaj
working hours.
D. If the GRANTEE has an independent audit, a copy of the audit shatl
be submitted to the STATE.
E. GRANTEE agrees that prior to subcontracting any funds received
under this grant contract it shall receive written approval from
the STATE.
F. Pursuant to Minnesota Statues, Section 176.I82 (1986}, GRANTEE
certifies it is a self-insured political subdivision-.
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IN WITNESS WHEREOF, the parties have caused this grant contract to be duly
executed intending to be bound thereby.
(1) GRANTEE , (3) ATTORNEY GENERAt
(If a corporation, t o orporate officers By:
must execute.) �
Date•
By
Title: r (4) COMMISSIONER OF ADMINIS7RATION
Date• By•
Date•
By: "
Title: Dir., Dept. of Ccmmunity Servioes (5) COMMISSIONER OF FINANCE
Date: °� Z-P' ,�� � By:
Date•
(2) STATE AGENCY OR DEPARTMENT:
By:
Title:
� Date:
Misc./contract � .
12/28/87
sjt
GRAl�'I�E
By:
Title: Dir., De t of Finance & Managanent
Date:
APPROVED AS TO FORM:
1�J f
Assistant City A torney
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Exhibit A
COUNSELIN6 AND' TEST SITE INYQICE �
CONTRACTOR Name:
Address: '
Telephone Number:
Service Period:
CONTRACTOR's Agent Signature:
Counseling Services
(#) persons counseled @ � �person
Testing .
(#) screening tests performed @ a /test
(#) screening tests performed @ � /test
TOTAL
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Hea 1 th Woricer
�lttachment A
, AIDS RISK ASSESSMENT
is information is private. No names lease! The questions can help you identify whether
you may have been exposed to t�ie IDS virus. Your responses will be shared oniy with the'.
counselor/nurse, and then will become part'of an anonymous (no names) data base used to
help us plan and evaivate heatth programs. Filling out the form is voluntary and wi11 not
be used to deny services.
CIRCLE ONE True - T False - F Don't Know - DK
T F DK 1. AIOS is an illness in which your body cannat fight aff diseases.
T F DK 2. You can usually tell �fif you've been infected with the AIOS virus.
T F OK 3. If you are infected with the AIDS virus you can infect cthers.
T F DK 4. A person can get AIDS by sharing rteedles and syringes with
an infected person.
T F DK 5. Anal intercourse may increase your chances of getting. AIDS.
T F DK 6. Having sex witfi someone who has AIOS is one way of getting it.
T F DK 7. If a preqnant woman has AIOS she� can give the virus to her
unborn baby.
T F OK " 8. Anybody can get AIDS.
T F DK 9. Condoms (rubbers) are 100� effective in preventing AiaS.
T . F DK 10. There is a blood test available which can teT1 you if you
have been infected with the AIOS virus.
11. List three ways to protect yourself and athers from gett�ng
AIDS: �
a. b. c.
yes / no / �nsure 12. Have you, or a sex partner, had a blood transfusion between
1917 and June, 1985?
yes / no / unsure 13. Do you or a past or present sexual partner have a bleedfng
disease (hemopi�jlia)?
yes / no / unsure 14. Have you had sex with more than one person in the past six years?
15. Approximately how many sex partners have you had during the
past two years?
10 or More 5-9 2-4 1 None
16. Approximately how many sex partners have you had during the
past three months?
10 or More 5-9 2-4 I None :
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,:
17. How often do you use rubbers whert having vaginal se�c?
Always Sometimes Almost Never _,�tever
.,,
18. If you don't like to use condoms, please say why you don't.
_,�es i no / unsure 19. Have you had anal sex (sex in the rectur;?
20. If you have had anal sex, did you use condoms?
Yes No Not Applicable
yes / no / unsure Z1. Have you ever had sexual contact with a person of the same sex?
yes / no / unsure 22. Have you, or a sex partner, had a sexually tran�mitted disease -
during the past six years?
yes / no / unsure 23. There have been many cases of AIDS in Centrai africa an� Nait? .
Have you, or a sex partner, had sex or•� used street dru5s
injected by needles while in these countries or with someone
who has 1 i ved i n th�ese_ countr�e� —""' — �"" '------
yes / no / unsure 24. Have you, or any of your sex ��partners, had QIOS, AIDS symptams,
or a positive blood test for AIDS?
25. It is important to think about your sex partner's partners .
yes / no / unsure - Do you think any of yaur sex partners have had
sex with other women?
yes / no / unsure - Do you think any of your sex partners have had
sex with other men?
yes' / no / unsure - Do you think any of your se�c. partners have had
-sex with both men and women?
yes / no / unsure - Do you think any of your� sex partners have had
sex with people who have used street drugs
• � . injected by a needle?
yes / no / unsure 26. Have you ever had unplanned sex because you were high? (Under
the �influence of alcohol or drugs such as cocaine, marijuana,
speed, crack, etc.)
yes / no / unsure 27. Have you, or a sex partner, ever used street drugs 1n3ected
by a needle?
28. Now often do you use street drugs �njected by a need.le?
Regularly Sometimes Once or Twice Never
Your Age Grade Completed Your Race: White Americart Tndian
Black :Hispanic�
�ale� Female Asian acific Islander Qther
-.,�,,._ _
Marital Status: Never Married Married Widowed ' Divorced Separated
Your main source of AIDS information: Friends Parents
T.V./Newspaper Nealth �1 nic
School
QUESTIONS OR CONCERNS ABOUT AIDS?
Office Us:e Only:
Minnesota AIOS Line: Twin Cities: (612)870-0700 "At 'Risk Yes N
. Greater MN: 1-800-248-AIDS Test Yes N
Minnea�olis Health Deaartment `Re�erred Yes h'
. . ' HIY COUNSELIN6 ANO TESTIt� �� � � 3`�(9-�3) aTTACfl►�EttT S
PATIENT INFORMATION
Site Code: ITI Date Tested: ITI/ITI/ITI ID No.
(i-z) � T3-8f' �
-� Marital Status:
Age: I_I_I ' (18
(ia-is)_ • E1) i_I Singl e '
Sex: I`i Male (1) (2) 1 I Married
• (16) i_I Femal e (2) (3) (-1 Oivorced
(a) I—) Separated
Race:l I White (i) i—i Asian �5) (5) I f Widaw/Widower
(17) I I Black (z) I_I •Other (6) (6) I_i Refused/Unknown
I I Hispanic (3) . -
( I Amer. Indian- (a) '
County of residence: I�_I (for office use)
i9-21)
Results: EIA: WB: Post-test Counse : _
(22) (2s) - (2a) .
(i)I_I Non-reactive ti) I_1 None (i) I_I Yes
(2)I_I Reactive (2) I_I Negative (2) i_I Na
(3) I_I Positive
(4) i_I Indeterminate
Primary Reason for Test: Prioiary Referral Source: (check one)
�25) �26�
(1) I I Screeni ng (i)1_1 Sel f-motivated
(�; I I HIV contact (2)I_) Infected Partner
(3) i_i HIV symptoms (s)I_I Health Dept. Representative
, (a)��) PtLysi ci an� . � '
(s)(_I Soci al Servi ce Agency _
Ri sk 6roup: I(e)I_I Other
(check all which apply) ( (specify )
. I
(2�)I_I Gay � .
(2s)I_I Bisexual ' Neterosexual contact with:
(29)I_I IV drug use � '
(3o)i_I Male prostitute (34)I—I Bisexua] �
(31)I_I Femal e prosti tute (ss)I—I IV drug user
(32)I I Born i n hi gh i nci dence country t36)I I Mal e prosti tute
(33)i—I Person wi th hemophil i a (3�)I I Femal e prosti tute
(3811 I Person with hemophil fa
�39�I_I Person born i�n high irtcidence
country
(ao) I I None of the above (explain)
(including tcansfusion recipient, health care worker. etc.)
Test History:
(41-42)
Number of months since last at-risk exposure: I_I_I
�3�
Previous anti-HIV test? I ! Yes (i) If Yes. number of months aa-4s)
1 1 No (2) since last test? I i I
Results EIA: MB: Site:
of last (a� (a�) � (as)
test: (13 I I Non-reactive (1)I_I None (i) I_( CTS
(2) 1_I Reactive (2)I�I Negative (2) ( I Physician
(3)I I Positive (a) I i Blood Bank
(n)i_I Indeterminate �(4) ( I Plasma Center
(5; I I Other •
- over - (spectfy)
Now many times has patient had anti-HIV test? I I I
ta9-5o
Has patient received any IG product (i.e., HBIG, Rhogam) in the past 6 months?
(1) {2) .
I I Yes i_I No If Yes, how many weeks ago? I�i
(51) �1) �2) �52-53)
Has patient received Hepatitis B vaccine? I I Yes ( I No
. 54� _
• � Risk Reduction
Number (total ) of different sex partners in last 3 months I��i
�55-57j
In last 12 months ITl—) �
(58-b0)
Number of partners of same sex in l ast 3 months (�l_I
(61-63)
In 1 ast 12 months I_I_�I .
�(64-66)
Number of different partners with whom needl es have been shared in 1 ast 12
months
I I I I
(67-69)
Has patient donated blood or semen since 1977?(1)I—I Yes
' (2)I I No
If yes. Date Facility (�o) City. State
In the last 3 months. has patient engaged in: .
Anal Intercourse � �Vaginal Int�rcot�rse Sharing Needles
�.
With Condom: (1) I ( Yes With Condom: (1) I�I Yes (1) I ( Yes
(2) I I No . (2) I I No (2) I�t No
(71) � (73) 75)
Without Condom: (i) i—( Yes Without Condom: (1) I�) Yes
(2} I I No t2) I I No
(i2) � (ia)
Is patient aware of safe sex practices?' (1) I ( Yes
(2) i i No _
(76)
Has patient ever. been treated for syphilis? (1) i I Yes If Yes, date last:
t2) I I No (�s-si)
(n) I I t/1 I t
T
Mo. Yr.
Where does patient get"the most reliable information on AIDS?
(check all that apply)
(s2)I I TV (ss)I I Daily Newspapers (as) I I Don't know
(a3)I_I Radio t86)I I Friends (89) ( I Other
(8a)I_I Gay Newspapers (s�)I_I Heal th Info. Services
Clinician Cou�selor Notes: �