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88-1725 wHiTE — ciTr CLERK COUt1C11 �, �] PINK — FINANCE G I TY O F SA I NT PA U L �S � � CANARV — DEPARTMENT �d BIUE —MAVOR File NO. � � - � Co ,uncil Resolution i� �;; �� ,_, Presented By �� Referred To Committee: Date Out of Committee By ' Date RESOLVED, that the proper City officials are hereby suthorized and directed to execute a contract with the 5tate of Minnesota, Minnesota Department of Health. WHEREBY, the City shall conduct a program designed to evaluate the risk of human immunodeficiency virus (HIV) among patients attending a public sexually transmitted disease clinic. The program will consist of two surveys which are funded by the Centers for Disease Control 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 Servi.ces. COUNCIL MEMBERS �. Requested by Department of: Yeas Nays �ia�ua�}-�� Lo� In Favor Goswitz , Rettman . B ��Z1__ • � s�ne�be� _ Against y S�*++�rt- Witson „ .., .�,Q Qi;� ` ( ��(7 Form A by Cit Att ney Adopted by Council: Date � Certified Passed ncil Secreta BY By � . 4 + ��$$ Appro Mayor for Submissi n o oun '1 t�pprov y Mavor. a e g BY " �1.15l�QI !:{3�i . , 198� �'�-- 1 `7a� .�°_ 0142(�5 Ca[rtnunity Service� DBPARTMENT - - - - M�rY �-n CONTACT NAME , . �292-7735 PHONE ' Octo�er 4, 1988 DATE . ASSIGN NUMBER FOR ROIITING ORDER: (See reverse��I�� \� � RE�1� ' � Departmeat Director ��T .l � 1988 —3 ?tayor (or Assistant) DCT � 4 � �' Finance and 14anagement Ser•vices Directo 4 Gity Clerk Budget Director ,._..._..,.��y� ' •City Attoritey MAYOR'S OFFIC� . �OTAL NUMBER OF SIGNATURE PAGE&: 1 (Clip all locations for signature.) , WHAT WILL BE ,�CflZEVED B TARINQ 1lCTION ON THE ATTACHED MATBRIAI.S? (PurpcsseJRationa�.e) Resolution to allvw Ci:ty signatures on an ac�resre.nt bet�z the City of Saint Paul, �.igh �� . Division of Public Hea].th and the Mismesota De�art�rnerit o€ I�ealth. L1nc�er the ternns a� th� : �'``'�s tY'aCt, the Dlvision of Public Health will c�or�duct a a�n desi ,�� progr gned �bo evralvate the ` of hunat> ;mtaa�-�deficie�c,y virus (IiIV) �rong P�tients att�c3ing a publio sexua�.ly : �°s A,�'q 'tt�ed disease clinic. �e progran will consist of tva� suxveys, which are fta�ded by for Di�ease C.ontrol as part of th�e Fa4nily of S'urv�y5 to assess prc�al�oe of; ection in variaus popul.ations. ? � SONNEL I CTS C P D: will be received frcm the Mir�nesota. Department of Heal�:h fc�r the oo�tr�ct period! fram ��: 1, 1988 th�h April 29, 1989 for part one ar�d: far th�e periad of S�t�r k, 1988 l�a�a�es 30, 1988 far part ts�uo. Zbtal a�rbunt of oontract is. $�6,91��ATo per�l u�aacts a�ticiFated• �,\ � 0�� : /t/�.� - �� v o n ��£°� 13�9B � FINANCING $OORCE AND BUDGET ACTI ITY NIJMBER C�IARGED R CRE I�'ED:�N� R�'� j'hF 8 (l�ayor•s sig�atuze not required if under $10.400.) �6�„�HT�D/�� -.��•� �t w4Z'� a Total Amount of Trans�ction: $26,915 Activity Pumber: 33�42��1� Funding Source: �,��„yp{� ��t of Health � . �� ; �i;�TACHIiENTS: (List and number all attachments.) ��G - ' 1. f'' ��t� oriqinal. ar�d faur c�pi�uncii Research Center 0�� 0�� ` �� a. . OCT 171988 �'/J' S,9 �;; f" � �, g8 �/�;a '� ADMI�IISTRATIVE YROCEDURES - _Yes _No R�les, Regulations, Procedures, or Budget Amendment required? - + �Yes _No If yes, are they or timetable attached? DEPARTI�tENT REVIEW CITY A�TflRi�Y &BVIEW _Yes _No Council resolution required? Resolution required� _Yes Nb. • _Yes _No Ia►surance required? Insurance sufficient?`�Yes _1�� _Yes� _No Insurance attached? .,�:� ..,.�:.�._.....�.;_ , y�'CHEyy�q� - ... ; r..� �;:;;"'�°:=Q STATE OF MINNESOTA �U"1'7�-� <:''�:s�rs �.. �s--;z ��:�� CONTRACTUAL (non-state employee) SERVICES <.;,�.r. Trn. No. FY Account I.D. Dept./Div. Sequence No. Suffix Object Vendor Type Amount / NA40 9 390120 12 500 26732 Ol 722 066001007 V 26 / Purchase Terms Asset No. C.CD. 1 C.CD. 2 C.CD. 3 Cost Code 4 Cost Code 5 570 ' ¢ , J� � umber Entered By Type of Transaction a A 40 ❑ A 41 /� � �,li, Ll _ 'f<<i Date umber ,. Entered By � A 44 � A 45 � A 46 NOTICE TO CONTRACTOR: You are required by Minnesota Statutes, 1981 Supplement, Section 270.66 to provide your social security number or Minnesota tax identification 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 numbers could result in action to require you to file state tax returns and pay delinquent state tax liabilities. This contract will not be approved unless these numbers are provided. These numbers will be available to federal and state tax authorities and state personnel involved in the payment of state obligations. THIS CONTRACT, which shall be interpreted pursuant to the laws of the State of Minnesota, between the State of Minnesota, acting through its�nar .m nt nf �pal�7 (hereinafter STATE) and ThP ('i t� nf C�h Pa�il arti n� through '1'kS H��1�kh Bepar�kmen+ address .�+ o��l nnni ��ini Soc.Sec.or MN Tax I.D. No. taY aYamnt Federal Employer I.D. No. (if applicable) , (hereinafter CONTRACTOR),witnesseth that: WHEREAS,the STATE,pursuant to Minnesota Statutes 144005 (b� isempoweredto nrnvi�la fnr tha nr�an;�at;nn �f S�1^V168S fAl^ the—P�ever��i-e+�°"'a„c�vTr-�r"vi--��''a-'i-"s�c"r'sc ,and WHEREAS, pursuant M.S. 1 4 , the ommi ioner o ealth is empowered to enter in contractual aqreements with any public or private_entitv for the provision of statutorily,and WHEREAS,CONTRACTOR represents that it is duly qualified and willing to perform the services set forth herein, prescri bed heal th NOW,THEREFORE,it is agreed: S21"V7 C25. 1. CONTRACTOR'S DUTIES (Attach additional page if necessary). CONTRACTOR, who is not a state employee, shall: Perform the duties described in Exhibits A, D and E, attached hereto and made a part hereof. /�do� ��o/y� A�ua6y — uaa�� Ado� asuadsnS A�ua6y — �/ui d luawl�edaa uo�ie�3siu�wpy — uow�es �ol�e�luo� — �fieue� 1�un 6uiluno��y A�ua6y — an�g 1uawl�edap a�ueui j — a�iyM a3ep a1eQ a�1�1 (a�nleu6�s pazi�oylne �alue� a�ue�qwn�u3) Ag a�nleuBis ( paz��oylne) Ag ' ". : .�� 3�N`dNl�-�O ti3NOISSIWWO� 5O ' ": �•1N3Wlab'd3Q a0 .l�N3Jt/ 31b'1S ZQ �� 'I °� a3ea Iil. CONOITIONS OF PAYMENT. Aii services provided by CONT4ACT0??i pursuant to this contract shall be performed to the sat- isfaction of the STATE, as determined in the sole discretion of its authorized agent;and in accord with all applicable.sederal,s'ate and local laws, ordinances, rules and regulations. CONTRACTOR 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 CONTRACT. This�contract shall be effective on ��±o@�p�{.ir� � , 19$$.—, or upon such date as it is executed as to encumbrance by the Commissioner of Finance, whichever occurs later, and shall remain in effect until , , 19_$9—, or until all obligations set forth iR this contract have been satisfactorily fulfilled, whichever occurs first. V. CANCELLATION. This contract may be cancelled by the STATE or CONTRACTOR at any time, with or without cause, upon thirty (30) days' written notice to the other party. In the event of such a cancellation CONTRACTOR shall be entitled to payment, determined on a pro rata basis, for work or services satisfactorily performed. Vi. STATE'S AUTHORIZED AGENT. The STATE'S authorized agent for the purposes of administration of this contract is Such agent shall have final authority for acceptance of CONTRACTOR'S services and if such services are accepted as satisfactory, shall so certify on each invoice subrriitted pursuant to Clause II, paragraph B. VII. ASSIGNMENT. CONTRACTOR shall neither assign nor transfer any rights or obligations under this contract without the prior . written consent of the STATE. � - -4 '- VIII. AMENDMENTS. Any amendments to this contract shall be in writing; and shali be executed by the same parties who executed { �r the original contract, or their successors in office. - -� --�—' IX. LIABILITY. CONTRACTOR agrees to indemnify and save and hold the STATE, its agents and empioyees harmless from any and all claims or causes of action arising from the performance of this contract by CONTRACTOR or CONTRACTOR'S agents or employees. This clause shall not be construed to bar any legal remedies CONTRACTO.R may:have for, the STATE'S failure to fulfill its obligations pursuaM.to this contract.: •� ' : � . _... X. STATE AUDITS. �he books, records, documents, and accounting procedures and practices of the CONTRACTOR relevant to this contract shall be subject to examination by the contracting department_and the legislative auditor. _ XI. OWNERSHIP OF DOCUMENTS. Any reports, studies, photographs, negatives, or other_documents prepared by CONTRACTOR in the performance of its obligations under this contract shall be the exclusive property of the STATE and all such materials shall be remitted to the STATE by CONTRACTOR upon completion,.termination or cancellation of this contract.CONTRACTOR shall - � ' not use, willingly allow or cause�to have such materials used for any purpose other than performance of.CONTRACTOR'S obli- �- -gztions under this contract without'the prior written consent of the STATE. ' ' _' '� .� � � � � XII. AFFIRMATIVE ACTION. (When applicable) CONTRACTOR certifies that it Mas received a certificate of com�liance from'the ..Gommissioner of Human Rights pursuant.to Minnesota Statutes, 1981 Supplement, Section 363.073. - � � XIIC.�VIIORKE•R$'_COMPENSATION. In accordance with the provisions of Minnesota Statutes; 1981 Supplement;Section 176.182, the � � ��STbT'E�a�firms�that CONTRACTOR has provided acceptable evidence of compliance with the workers' compensation insurance �coverage�equi�ement of Minnesota Statutes, 1981 Supplement, Section 176.181, Subdivision 2. XIV. ANTITRUST. CONTRACTOR hereby assigns to the State of Minnesota any and all claims for overcharges as to goods and/or services provided_ in connection with this contract res.ulting from antitrust violations which. arise under. the antitrust laws of the Un'ited States and the antit�ust laws of the Stafe of'Minnesota. � , : _ XV. OTHER-PROVISIONS. (Attach additional page if necessary): � r WITNESS WHEREOF,the parties have caused this contract to be duly executed intending to be bound thereby. APPROVED: NOTE: Remove carbons before obtaining signatures. As to form and execution by the • CONTRACTOR: Q3 ATTORNEY GENERAL: (If a corporation,two corporate o 'cers must execute.) By D ev N N � . . . _ . � � . Ma �+ � . . . . . � oace �f�� 1 ^ \ � m J. (� � t . . � , .. .. . . eSD 4 . : �� -/�iyT� �0 4Q COMMISSIONER OF ADMINISTRATION: 0 BY -Y By(authorized signature) . � fD �G � � Title . . , . . � . .. . �. - Date - ... . .. ... . . .. � .. .. .�. Il;ror+nr Cnmm�mi tV SP1^V1 CES � . . ` -�f��7�.� St. Paul Division of Public Health Room 111 Clinic Exhibit A Contractor's Duties The CONTRACTOR, who is not a STATE employee, shall , for a period beginning September 1, 1988, and ending April 29, 1989, conduct a program designed to evaluate the risk of human immunodeficiency virus (HIV) among patients attending a public sexually transmitted disease clinic. The program will consist of two surveys, which are funded by the Centers for Disease Control as part of the Family of Surveys (FS] to assess prevalence of HIV infection in various populations. The two surveys are: 1) a FS non-blinded HIV seroprevalence survey of patients attending STD clinics, to �begin October 1, 1988, and to continue until 430 participants have been enrolled or until no later than April 29, 1989, whichever comes first. 2) a FS double-blinded HIV seroprevalence survey of patients attending STD clinics, to begin September 1, 1988, and to continue until 1,100 eligible specimens have been obtained or until no later than November 30, 1988, whichever comes first. I. The FS Non-Blinded HIV Seroprevalence Survey of Patients Attending STD Clinics For this survey the CONTRACTOR shall follow the protocol in Exhibit D - - "A Non-Blinded HIV Seroprevalence Survey of Patients Attending Sexually Transmitted Disease Clinics." CONTRACTOR'S duties shall include the following: A. Select and enroll potential participants using a predetermined sampling scheme, as described in the protocol . B. Inform and interview enrolled patients who have agreed to participate in the survey using a consent form and a standardized questionnaire provided by the STATE. C. Draw blood from participating patients and submit the specimens to � laboratories approved by the STATE for HIV antibody testing. D. For participants desiring to know their test results, counsel each person about the HIV antibody test and include: 1. assessment of the person's emotional response to the test results; and 2. information about the meaning of the test result for the person; and 3. risk reduction and disease prevention recommendations specific to the person's risk of exposure to HIV; and 4. referrals for medical evaluation and psychosocial support; and 1 / ��r/?�� . 5. counseling about notifying and referring their sexual and/or needlesF�aring partners for the purpose of HIV risk reduction and disease prevention counseling and antibody testing. E. Record laboratory results onto the completed questionnaires. F. Present completed questionnaires and Non-Participant Forms to STATE on a monthly basis until 430 participants have been obtained or until no later than April 29, 1989, whichever occurs first. II. The FS Double-Blinded HIV Seroprevalence Survey of Patients Attending STD Clinics For this survey the CONTRACTOR shall follow the protocol in Exhibit E - "A Double-Blinded HIV Seroprevalence Survey of Patients Attending Sexually Transmitted Disease Clinics" . CONTRACTOR'S duties shall include the following: A. Select eligible serum specimens (drawn for syphilis testing) using predetermined eligibility criteria as described in the protocol . B. Complete survey forms indicating county of residence, age, sex, race, risk exposure group and reason for clinic visit. - C. Label both the syphilis serology specimen and the survey form with - identical code labels. D. Send selected serum specimens to the STATE, as per usual for. syphilis serology testing. ' E. Send survey forms to the STATE on a weekly basis until 1,100 specimens have been received or until November 30, 1988, whichever occurs first. 2 . . � ��,�� St. Paul Division of Public Health Room 111 Clinic Exhibit B Considerations and Terms of Payment A. For services performed in this contract, CONTRACTOR shall : 1. Receive the rate of reimbursement of thirty dollars (�30.00) for each person who is enrolled in the FS non-blinded HIV seroprevalence survey of patients attending STD clinics. For each participant in the survey who receives post-test counseling, the CONTRACTOR shall receive twenty-five dollars ($25.00) . 2. Receive the rate of reimbursement of five dollars ($5.00) for each syphilis serology specimen selected for the FS double-blinded HIV seroprevalence survey of patients attending STD clinics. � 3. Receive reimbursement for the actual cost of HIV serologic tests, not to exceed rates shown in a) through b) below, for each person who is enrolled in the study and who completes the questionnaire. CONTRACTOR shall not exceed these amounts without prior written consent of the STATE's authorized agent for this contract. - a) Five dollars ($5.00) per HIV antibody screening test (EIA) - performed for the FS surveys. b) Forty-five dollars �($45.00) per F.D.A. licensed confirmatory test (DuPont Western blot) performed for the FS surveys. _ c) The total reimbursement by the STATE for HIV antibody screening and confirmatory tests performed for the FS non-blinded survey of patients attending STD clinics shall not exceed three thousand one hundred forty dollars ($3,140) without the written consent of the STATE's authorized agent for this contract. B. CONTRACTOR shall present invoices for services performed monthly, no later than the twenty-fifth calendar day following the month of invoice, reflecting only those services performed during the month of invoice. C. Invoices for services performed shall be presented on forms provided by the STATE (Exhibit C) according to the line item budget as follows: 1. COUNSELING SERViCES 430 persons pre-test counseled as part of the FS non-blinded survey of STD clinic patients @ $30.00/person $12,900.00 215 persons post-test counseled as part of . the FS non-blinded survey of STD clinic patients - @ $25.00/person 55,315.00 3 ��7�� ., 2. SERUM SELECTION FOR THE DOUBLE-BLINDED SURVEY 1 ,100 sera selected as part of the FS double-blinded survey of STD clinic patients @ 55.00/specimen 35,500.00 3. TESTING SERVICES 430 screening tests for the FS non-blinded survey of STD clinic patients ` @ �5.00/test a2,150.00 22 confirmatory DuPont Western blots for the FS non-blinded survey of STD clinic patients @ 545.00/test 5990.00 Total �26,915.00 . D. No more than 10% of the funds identified in line item amounts shown in C. (above) may be transferred to other line items or used for any - other purpose without the prior written permission of the STATE'S authorized agent for this contract. , 4 � ' �VV r/!�� i St. Paul Division of Public Health R�om 111 Clinic Exhibit C Invoice for the Non-Blinded and Double-Blinded Surveys CONTRACTOR: Name: Address: Service Period: CONTRACTOR'S Agent Signature COUNSELING AND TESTING SERVICES FOR THE FS NON-BLINDED SURVEY OF STD CLINIC PATIENTS persons pre-test counseled as part of the survey _ of patients attending an STD clinic @ $30.00/person = persons post-test counseled as part of the survey of patients attending an STD clinic @ $25.00/person = • EIA screening tests performed after September 1, 1988 - @ $5.00/test = Confirmatory DuPont Western blots performed @ $45.00/test = _ SERUM SELECTION FOR THE FS DOUBLE-BLINDED SURVEY OF STD CLINIC PATIENTS sera selected for the FS double-blinded survey @ $5.00/specimen = TOTAL 5 �"��'%� St. Paul Division of Public Health Room 111 Clinic Exhibit D A Non-Blinded HIV Seroprevalence Survey of Patients Attending an STD Clinic I. Background This survey is one of the surveys within the Centers for Disease Control Family of Surveys. The purpose of the Family of Surveys is to assess prevalence of both HIV infection and risk behaviors for HIV infection in various populations. A questionnaire will be provided by the Centers for Disease Control (CDC) . This survey will begin on October 1, 1988, and continue until approximately April 29, 1989, when 430 participants have been enrolled. II. Goals and Objectives A. To estimate HIV prevalence in STD clinic patients by age, sex, race, and sexual orientation. - B. To ascertain risk behaviors associated with HIY infection in STD clinic patients. ^ C. To monitor trends in HIV infection levels and risk behaviors over time. III. Methods A. Inclusion/Exclusion Criteria 1. Patients will be eligible for inclusion 1) at their initial visit for a new disease episode and 2) if they have not visited the clinic within the previous 90-day period. ' 2. Patients making follow-up visits for previously diagnosed disease episodes during the survey period will be excluded. 3. Asymptomatic patients attending STD clinics solely for reasons of HIV testing and counseling will be excluded from the survey. 4. Study subjects will include those individuals, who by local law, can give their own consent. B. Enrollment Procedures 1. The clinic will enroll an average of four patients/day for a total of 430 patients over the six-month survey period. 2. Clinic staff will use a sampling procedure that is similar to .� � the one used in the current (HIV/HBV) survey being conducted at - the clinic: 1 � . � - C�'��-�� a) a separate listing of STD clients is maintained at the time the patient registers, b) upon opening the clinic, the lst, 5th, 9th and 13th STD clients seen on each day (total of 4 daily) will have their chart marked by the secretary to be enrolled in the study protocol and have appropriate blood samples obtained • and survey administered. 3. Clinic staff will examine patient's charts to determine if they are eligible for the survey. If eligibility criteria are satisfied: a) the clinician will use an information sheet, provided by the MDH, to explain the survey to the patient. b) the patient will be given a consent form to read, or will have it read to them by the clinician. If the patient wishes to participate, oral consent will be obtained. c} for patients consenting to participate, the clinician will . aa) answer any questions that the participant might have regarding the survey. , bb) provide pre-test counseling. _ cc} interview the patient with the standardized questionnaire. dd) obtain one tube (approximately 7 ml) of clotted - blood (red top tubes) from the patient and label it with a code number taken off the CDC questionnaire form, which has a matching code number. ee) inform patients that they should make an appointment to learn of their HIV antibody test results. Post- test HIV antibody counseling will be offered at that time. Patients who are HIV antibody positive and do not have any apparent risk factors for HIV infection (i .e. male-to-male sex, intravenous drug use) will be re-interviewed by the clinician and possibly MDH staff to ascertain a risk factor. C. Participant Recruitment Categories 1. The clinic will enroll 430 participants in the survey. Of these 430 participants: a) 70 will be homosexual/bisexual men. _ ., b) 180 will be heterosexual men. c) _ 180 will be women. . 2 ��,�� 2. The clinic will maintain an ongoing tally of the number of participants fitting into the three categories . When a sufficient number of participants within a given category have been recruited, clinic staff will no longer recruit patients within that category. D. Follow-up of Refusers This survey will not require follow-up interviewing of patients who are eligible for the survey but refuse to participate. However, the clinic will record the number of eligible patients who refuse to _ participate on a "refuser" form to be provided by the MDH. In this way the overall participation/refusal rate will be determined. E. Laboratory Testing Blood specimens from the Room 111 Clinic will be sent to the American Red Cross, St. Paul Regional Blood Center. Testing for HIV antibody will be performed on all specimens. F. Recording of Results 1 . The clinic will retain questionnaires until laboratory results are received by the clinic. Clinic personnel will record the laboratory results onto the questionnaire when the results are received at the clinic. 2. Completed questionnaires, with laboratory results recorded on them, and the refuser forms will be delivered to the MDH by courier for coding and keypunching. Copies of test results will also be sent to the MDH for verification and quality - control purposes. IV. Reimbursement The Room 111 Clinic will be reimbursed at a rate of: • A. 330 per patient who: 1 ) gives consent, 2) receives pre-test counseling, 3) is interviewed and 4) is HIV antibody tested. Laboratory tests will be paid for as specified in contracts between MDH and the clinic. The clinic will only be reimbursed for patients completing steps (1) through (4) above. B. �25 per patient who was pre-test counseled, interviewed and HIV antibody tested, and returns to obtain HIV antibody test results and post-test counseling. V. Analysis and Results A. Questionnaires will be reviewed by the survey coordinator (John Thomas) . Clinic personnel will be contacted by telephone or in person to clarify questions or correct errors regarding data on the _� questionnaires. 3 , .� � �c�'�� B. The MDH will provide the following summaries to the St. Paul Division of Public Health and the Room 111 Clinic on a monthly basis for the dur.ation of the survey (a one to two month lag between the beginning of the survey and receipt of the first report may occur) : 1. basic frequency distributions for each item on the questionnaire. 2. survey participation/refusal rates. 3. seroprevalence by age, race, gender, sexual orientation, county of residence and zipcode. 4. correlations of HIV antibody test results with questionnaire data. These reports will be provided on either computer diskette or paper copy, whichever the recipient prefers. 4 ��'�'�3� . N0� BII�iDED HIY SEROPREVAIENCE SURYEY OF STD PATIENTS INFORMATION SHEET CODE NUhiBER The Minnesota Department of Health (MOH) , the Hennepin County Health Department Red Door Clinic, and the St. Paul Division of Public Health Room 111 Clinic are conducting a study of AIDS virus infection among patients being seen at sexually transmitted disease clinics. We hope to learn what the level of infect�on is and to determine what factors correlate with an AIDS virus infection. You are being asked to participate because we are asking a sample of all sexually transmitted disease clinic patients seen at this clinic. To obtain an accurate assessment, it is extremely important that all perSOns who are selected to participate actually enroll in the study. If you decide to participate, you will be interviewed regarding your past � behaviors that may have put you at risk for being infected with the AIOS virus. After the intervierv is completed, a nurse/clinician aill draw a blood sample from your arm. One tube of blood, about 2 tablespoons, wfll be drawn. The risk of complications from blood drarring are extremely small . In the rare event of subsequent complications, you rrill be responsible for your own medical care and costs. The interview and blood drawing will take about 20-30 minutes. Your blood sample will be tested for evidence of infection with the AIDS - virus. You can make an appointment to return in about two weeks to find out what your test results are. ur results �g identified � code um r � t�e ure � rin � � wi ou when yp,� rn. If your test result is � positive, you will be asked to provide your name and other identifying . information. That information will only be used for public health purposes and will remain confidential . However, if you do not provi�de that information, you will not be denied counseling or test results. Your decision whether or not to participate in this study will not affect your future relations with this clinic or HDH. Once you decide to participate, you may Nithdraw at anytime. If you have any questions about this study, please ask now, or call this clinic (Red Ooor -- 347-3300, Room 111 - 292-7752, or the MDH - 623-5414}. You can keep this copy for your own records. Interviewer . _ _ _ _ __ __ _ _ _ � . �� - �� OMB No. 0920-0232 Exp. Date: April, 1991 RISK ASSESSMENT QUESTIOPdNAIRE TO BE USED IN A NON-BLINDED SURVEY �,NSFIERS NILL BE LIIr'KED TO HIV TEST RESULTS ' STD Clinics: For men only (INTERVIEWER: THIS QUESTIONNAIRE IS FOR MALE PATIE2'TS ONLY. PLEASE COMPLETE ITEMS 1-6) 1. Study Nuraber 2. Project Area �_�_� Site �_� Month Year 3. Date: This visit I=I—I (—I_—I Last visit 4. HIV test counselir,g at this visit1CHECK ONE) Pre-test �_� Post-test �—I " 5. Patient's residence: State " County I_I—I—� Zip Code ,I—I—I—I—I—I 6. Sex (INTERVIEWER: CODE APPARENT SEX) �_� Male �_� Female (INTERVIEWER: READ THE FOLLOWING INFORMATION TO THE PARTICIPANT) The purpose of this intervieW is to gather information about the spread of the virus that causes AIDS. Your name Will not appear on this questionnaire. None of your ansWers Will become part of your record at this cliriic or elsewhere. This interviev is voluntary. Some of these questions are about your use of drugs and your sexual behavior. You don't have to answer any questions you feel are too personal. If you have any qvestions, feel free to ask me or anybody else on the clinic staff, at any time. Thank you for . ansWering our questions. (INTERVIEWER: CHECK ONLY ONE ANSWER UNLESS OTHERWISE SPECIFIED. DO NOT READ THE ANSHERS UNLESS SPECIFIED.) . , � � 7. What is your age? �_�_� Years 8. Nhy are you visiting the clinic today? (INTERVIEWER: PROBE BUT DO NOT READ ANSFlERS - CHECK ALL THAT APPLY) _ Requesting HIV test Health department/STD referral _ Follov-up STD visit PMD/Blood Bank/Hospital referral � � STD exam/treatment, symptomatic HIV/AIDS disease _ STD exam/treatment, asymptomatic _ Not ill; Worried about HIV Referred by HIV+ sex partner Other Referred by sex partner vith STD Don't knov Referred by health department/HIV Refuse to ansver infc qu•sflonn�lr� Is �utnorla�0 Dy lar (PuD�lc Nw 11� Srrvlc• Act, �2 USC 2111. AItAc..;�n r�cpons• to tM au�ctlons ask�E Is volunt�ry, cwD�ratlo of tn� p�tl�nt Is n.c�aw rr tor tn• atray •nd control of tn• Als�s►�. Pucllc r�portlnp G�rd�n lor tnlc colt•ctlon ot �ntorestlon Is +►tlret.a to �v�r��• IS •Inut�c p�� r�cponr�. S�nO w..+rnTS r�p�relny tnl� b,�a�n •at�m t• or •nr otnwr •aD�ct of tNlc eoll�ctlon of Inforrrtlon, inctu0lny sugy�stlons lor r�0uctnq tnit Wrdoe to PMS R+ports CI«sn nc• Olfic�r; it� )21-M, h�.�ynr�y tly; 2Cu InO�p�nO�nc+ Av�. SM; �eanlnyton, OC 20201; ATTH: PRA, �no to tn� p tic� ot Inforrotlon �n0 R+9ul�torr Att�irs, 011ic� ot w nayonrnt �nd Nuogat, w anington, DC 20503. � ��d��'i�a�. � 9. Soc,etimes doctors or hospitals give blood to their patients because of bleeding, durir.g surgery or for other reasons. Did you receive blood be*�een January 1978 and J�.:ne 1985? ' No (_I Yes 10. Since January 1978, how many times have you been told by a doctor or nurse that you had one of the folloWing: Do not include this visit. (INTERVIEh'ER: READ ALL ANS�TERS. ENTER NUPIBER OF TIMES. IF PATIENT DID NOT HAVE THE DISEASE, ENTER "00") _ _ gonorrhea, GC, clap, drip chlamydia _ _ syphilis _ genital herpes _ _ genital warts _ _ trichomonas, trich other STD 11. Since January 1978, have you evez used a needle and syringe to shoot street drugs? - I=INo (INTERVIEWER: IF N0, GO TO QUESTION 15). Yes 12. In the past 12 mor.ths, how often did you shoot street drugs? ( I�'TERVIEi�'ER: READ '�LL ANSri'ERS) Several times a day Once a Week ' Once a day Less than once a week Several times a week Never 13. Since January 1978, have you ever used a needle or syringe, that is, "works", after someone else used it or may have used it? - No (INTERVIEWER: IF N0, GO TO QUESTION 15). I_I Yes 14. In the past 12 months, have you ever used a needle or syringe, that is, "works", after someone else used it or may have used it? . I—I No Yes 15. Since January 1978, were the people you had sex with: (INTERVIEWER: READ ALL ANSWERS) Only men (INTERVIEWER: IF ONLY MEN, GO TO QUESTION 34) Only women Both, mostly men Both, mostly women . Both, about equal During the the next part of the interview, having sex with a woman means putting your penis in a Woman's vagina, rectum or mouth. 16. Hhat Was your age when you first had sex with a women? �_�_� Years �_� 17. Since January 1978, how many new female sex partners have you had, that is1 women with Whom you had not ,had sex before? (—�—�_�—� . . . . (�l`'��7'��5 18. In the past 12 months, with how cr,any different Women have you had sex? �—�—�_I—� (INTEP.VIEWER: IF "0", GO TO QU-ESTION 24 19. How many Were new sex �rtners, that is, �:omen with whom you had not had sex before? �—�—�—�—) . 20. In the last 12 months, have you had sex with a woman only one time and never again? I—I No Yes 21. These questions are about the different kinds of sex you might have had. In the past 12 months, have you ever: Yes No put your penis in a woman's vagina put your penis in a woman's rectum put your penis into a Woman's mouth i 22. In the past 12 months, when you had sex With a wonan who is your steady - aex partner, how often did you use rubbers or condoms? (Ii3TERVIEh�ER: READ ALL ANSWERS) _ Every time Never ^ _ Usually (half the time or more) I_( No steady sex partner _ Sometimes (less than half the time) ' 23. In the past 12 months, When you had sex with other Women, how often did you use a rubber or condom? (INTERVIEWER: READ ALL ANSWERS) _ Every time Never - _ Usually (half the time or more) I_I No other sex partners _ Sometimes (less than half the time) 24. Since January 1978, have you given a woman money or drugs to have sex? No (INTERVIEWER: IF N0, GO TO QUESTION 30). I_I Yes ' 25. In the past 12 months, have you given a woman money or drugs to have sex? No (INTERVIEWER: IF N0, GO TO QUESTION 30) . I_I Yes 26. In the �ast 12 months, hoW many Women have yoh given money or drugs for sex? �—�—�—�—� 27. In the past 12 months, when you gave a Woman money or drugs for sex hoW . often did (INTERVIES�TBR: READ ALL ANSWERS) Every Usually Sometimes Never time (half the (less than ._ time or more) half the time) you put your penis into her vagina you put your penis into her mouth . y ouu put your penis into her rectum 28. Hov often did you us� a rubber or condom? �_� I—� I—I I—I � : ��-i��- 29. Of all the wos�en �hom you gave noney or drugs for sex in the past 12 months, how many Were (INTERVIEh'ER: REeD �+ZL T?iE ?NSS�'EF.S) All Most Some None (half (less than . or more) half) Street prostitutes or hookers �_� �_) I_I I_I Prostitutes in a house, health club or massage parlor I—_I I—_I I_—I (—I Call girls or escort service Women you met at a crack house or other place where drugs are used �_� (_� I_I I_� 30. Since January 1978, have you had sex with anyone who shot street drugs with needles? _ No (INTERVIEWER: IF N0, GO TO QUESTION 33). Yes � _ Un]mown (Ii.�ERVIEWER: IF UNKNOWN, GO TO QUESTION 33). 31. Of the women you had sex with during the past 12 months, how many shot drugs with needles? - �_�_�_�_� (Ih'TERVIEWER: IF "0", GO TO QUESTION 33) 32. hlere any of these women your steady se�.�val partners? ' I_I No Yes 33. Have you ever had sex with a voaan �:ho has AIDS or has had a positive blood test for the AIDS virus? - No Yes Don't know (INTERVIEhtER: FOR MEN 4+TH0 HAVE HAD SEX ONLY WITH WOMEft, GO TO QUESTION 53 TO COMPLETE THE INTERVIEW) (INTERVIEWER; THE FOLLOWING IS FOR MEN h1Fi0 HAVE HAD SEX ONLY WITH MEN OR WITH BOTH MEPi AND WOMEi7) During the next part of the interview, having sex �ith a man means having a man's penis in your rectum or mouth or putting your penis in a man's rectum or mouth. 34. Flhat was your age WY:en you first had sex With a man? �_�_� Years �—� . 35. Since January 1978, hoW many neW male sex partners have you had, that is, men with whom you ha� not had sex before? �—�—�—�—� :_ . .. ,. . �c��as 36. These questions are about the different kinds of sex you might have had. Since January 1978, have you ever: Yes No had a man put his penis in your rectun had a man put his per.is into your mouth put your penis into a man's rectum 37. In the' �ast 12 ff�onths, with how many different men have you had sex? �_�_�_�_� (INTERVIEWER: IF "0", GO TO QLTESTION 42 38. How many Weze new sex partners, that is, men With whom you had not had sex before? �_�_I—I_I 39. In the last 12 months, have you had sex with a man only one time and never again? I_I No Yes 40. These questions are about the different kinds of sex you might have had. In the past 12 months, have you ever: Yes No had a �an put his penis in your rectum ' had a man put his penis into your mouth put your penis into a man's rectun put your penis into a man's moUth 41. In the past 12 months, when you had sex With a man Who is your steady sex partner, how often did you or your partner use rubbers or condoms? � (INTERVIEWER: READ ALL ANSFTERS). _ Every time Never _ Usually (half the time or more) I_I No steady sex partner _ Sometimes (less than half the time) 42. In the past 12 months, when you had sex with other men, how often did you or your partner use a rubber or condom? (INTERVIEWER: READ ALL ANSWERS) _ Every time Never � _ Usually (half the time or more) I_) No other sex partners _ Sonetimes (less than half the time) 43. Since January 1978, have you given a man money or drugs to have sex or has a man given you money or drugs to have sex? No (INTERVIEWER: IF N0, GO TO QUESTION 49). - I_) Yes 44. In the past 12 months, have you given a man money or drugs to have sex or has a man given you money or drugs to have sex? I—_I No (INTERVIE4IEY: IF N0, GO TO QUESTION 49) . Yes . 45. In the past 12 months, �,rith hoW many men have you exchanged money or drugs for sex? �—�—�—�_� . �a�f�7�� 46. In the past 12 months, �hen you exchanged money or drugs for sex With a �an r:ow often did (Iir'TERVIEw'yR: READ �I.L �,*iSh'ERS) Every Usually Sometimes Never time (half the (less than . time o� more) half the time) he put his penis into your rectum he put his penis into your mouth you put your penis into his rectum yov put your penis into his mouth 47. How often did you or the other man use a rUbber or condom? �—� (—I �—� I_I 48. Of all the men with whom you exchanged money or drugs for sex in the past 12 months, how many were (INTERVIEWER: READ ALL THE ANSWERS) _ . All Most Some None (half (less than or more) half) Street prostitutes or hustlers �_� �_� �—� �_� Men you met at a crack house or other place where drugs are nsed �_� �_� �_� �—I l+9. Since January 1978, have you had sex w�th anyone who shot street drugs • with needles? No (INTERVIEFlER: IF h0, GO TO QUESTION 52) . Yes Unlaiown (Ih'TERVIEWER: IF Ui1'KPiOWN, GO TO QUESTION 52). 50. 0£ the men you had s�.x With during the past 12 months, how many shot drugs with needles? (—�—�—�—� (INTERVIEWER: IF "0", GO TO QUESTION 52) 51. Were any of these men your steady sexual partners? , I—I No Yes � 52. Have you ever had sex With a man Who has AIDS or has had a positive blood test for the AIDS virus? No Yes Don't lrnow (�NTERVIEWER: ASK ALL PARTICIPANTS THE FOLLOWING QUESTIONS TO COMPLETE THE INTERVIEW) . . 53. hihat racial group do you belong to? Do you think of yourself as: 11NTERVIEWER: REAJ ALL ANS�TERS) Alaskan Native/American Indian • - Asian/Pacific Islander Black Flhite " Other, race (Specify: ) . . . . ��-��.�- � 54. Are you Spanish or Hispanic? No (IIr'TERVIEWE'R: IF N0, GO TO QUESTION 56) . (_I Yes 55. What is your Spanish/xispanic origin? Do you consider yourself: (INTERVIES,'ER: READ ALL ANSWERS) Cuban Mexican/Mexican American . Puerto Rican _ Other 56. Were you born in the United States? I—_I Yes (INTERVIEWER: IF YES, GO TO QUESTION 59) No 57. In what country Were you born? 58. How old were you �:hen you first moved to the United States to live? �_�_� Years 59. Are you living with someone you have sex with? I_I Yes 60. What is your marital status? Are you now: (INTERVIEWER: READ ALL ANSWERS) Married Separated � _ Widowed I_I Never Married - Divorced 61. FThat� is the last grade you completed in school? (INTERVIEWER: PROBE FOR DEGREE) _ Elementary School (Grade �0-8) College Graduate (4-Year Degree) _ Some high school (Grade 9-11) (_I Graduate Work _ High School Gradvate (Grade 12) _ Some College or technical training (no 4-year degree) This is the last question. Thank you for participating in our survey. Do you have any questions you would like to ask? . . �-�-��s . � 4 i ________________________________________________________________________________ OPTIONAL QUESTIONS Clinics�may choose to add optional questions to the questionnaire depending upon their public health needs and the populations they servec' 1. Since (date survey began in the clinic) have you participated in,this sUrvey? � No � Yes Don't lrnow 2. FIave you ever had your blood tested for the AIDS virus before? No Yes Don't lrnow (INTERVIEWER: IF NO OR DON'T KNOW, GO TO QUESTION 6) 3. When was the test done? Within -the last 6 months 6-12 months ago More than 12 months ago 4. Did you get the results of your test? - No (INTERVIEWER: IF N0, GO TO QUESTION 6) I—I Yes 5. What was the result of the test? . Positive (_I Negative 6. Since January 1478, have you had sex with someone who was from Haiti? I—I No Yes 7.. Since January 1978, have you had sex With someone who was from Africa? I=I No Yes 8. Since January 1978, have you had sex with a man who has hemophilia or a bleeding disorder? I-_I N° Yes 9. (INTBRVIEWER: For men only) Are you circumcised? � I—I No Yes . . _ ��7�s . � � �` �� (for clinic use) STD diagnoses and/or symptoms at this clinic visit (check all that apply): _ penile/vaginal discharge . ano-genital ulcer _ pelvic inflammatory disease _ pubic lice _ ano-genital warts ano-genital herpes non-gonococcal urethritis _ gonorrhea _ syphilis chlamydia trichomonas hepatitis B other sexually transmitted infection other IF AVAILABLE: VDRL/STS/xPR Hepatitis B antigen/antibody reactive positive I—I non-reactive � I_I negative ' . V" �-�7a�� . Study Number LABORATORY RESULTS ELISA �_� Negative �_� Repeatedly reactive �_� Not done . IFA (optional) Negative Positive ( _I Inconclusive I_I Not done Western blot (_� P17 (_� P24 (_� P31 �_� P51 �_� P55 �_) P66 (—) GP41 �_� GP120 �_� GP160 �._� Ho bands �_� Not done • ' . � � ��,�� OMB No. 0920-0232 Exp. Date: April� 1991 RISK ASSESSMENT QUESTIOt�tZnI&E TO BE USED IN A NON-BLINDED SURVEY ANSNERS NILL BE� LINKED TO HIV TEST RESULTS , STD Clinics: For vomen only (INTERVIEFJE&: THIS QUESTIONHAIRE IS FOR FEMALE PATIENTS ONLY. PLEASE COMPLETE ITEMS 1-6) 1. Study Number 2. Yro,ject Area �—�—� Site �_� � Ionth �ear . 3. Date: This visit I=I=I I_—I—_I Last visit 4. HIV test counseling at this visit1C�C1C ONE) Pre-test �_� Post-test �_� - 5. Patient's residence: State - County I_I_�_) Zip Code (_�_�—�_�_� 6. Sex (INTERVIEi�TEg: CODE APPAEENT SEX) �_I Hale �_� Fe�ale (INTERVIEKER: READ THE FOLLONING INFORMATION TO THE PARTICIPANT) The purpose of this interviev is to gather information about the spread of the virus that causes AIDS. Your name vill not appear on thts questionnaire. None of your ansvezs vill become part of your record at this clinic or elseuhere. This interviev is volimtary. Some of these questions are about your use of druga and your sexual behavior. You don't have to ansver any questions you feel are too personal. If you have any questions, feel free to ask me or anybody else on the clinic staff, at any time. Thank you for answering our questions. (INTERVIEHEE: CHECK ONLY ONE ANSKE& UNLESS OTHERNISE SPECIFIED. DO NOT READ THE ANSKERS UHLESS SPECIFIED.) 7. Khat is your age? �—�—� Years 8. Khy are you visiting the clinic today? (INTERVIENEx; PROBE BUT DO NOT �AD ANSHERS - CHECIC �ALL THAT APPLY) Requeating HIV test Health department/STD referral Follov-up STD visit PMD/Blood Bank/Hospital referral _ . STD ezaa/treatment, symptomatic HIV/AIDS disease STD exam/treatment, asymptomatic Not ill; Norried about HIV Referred by HIV+ ses partner Ocher Eeferred by sex partner vith STD Don't lm.ov Yeferred by health department/HIV &efuse to anaver T►la �w►itonw�Ir� Ia •rtworliN ►y {�• (I'.r�llt IWIT* S.rvlp Acf, /Z UtC Itti. Aitnwyn r�apona� fo TM �wiTla�t �sa�a It w�w�t�rT, coop.r�*la ol fM p�tl�nT I► •�C.�►r�fT IOf TM �ir�Y •wi Gw�Tfvl 01 fN �I►MM• �+OIIC f�porTl�y L../Ow lo! f1�1• coll�:tlon yI IPIylyil0�1 I• .s11r,t..1 to •..r�� !! •te�t�a v•r r.►v�c.. 5..� corr�Tt r.p.r�leQ tet► s..rt.e •�tlrt• or •�� ot�..� •av�cr ol i�i► w�l.ctlon a I�dor�.Tion. I�,.��ot.9 ��qy.►tlon� tu� rN..cl�g tnla e..r�r to Pxi R►Port► Ci..r�wc• Otllc.r• N. 7t1-++, ti.pnr.r ry: 700 In�.p.na.�c• �••. Sr; r.snlnyfun. OC 1u701; �T1M: tN�� sna io 7n. pl lu ol I�Ixrilw •n� R�y�t�ror1 Ml�ir�, pllc. ot wr..9...�p� •na Y�ay.t, r..�lny�on, 0. 'L0�03. ' �O� �7�J ' . 9. Sometimes doctors or hospitals give blood to their patients because of bleeding, during surgery or for other reasons. Did you receive blood betWeen January 1978 and June 1985? I-I N° Yes 10. Since January 1978, hov many times have you been told by a doctor or nurse that you had one of the folloving: Do not include this visit. (INTERVIEWER: READ ALL ANSKERS. ENTER NUMBEB OF TIMES. IF PATIENT DID NOT HAVE THE DISEASE, ENTER "00") _ _ gonorrhea, GC, clap chla.mydia _ _ syphilis _ _ genital herpes _ _ genital varts _ trichomonas, trich PID other STD 11. Since January 1978, have you ever nsed a needle and syringe to shoot street drugs? I=INo (INTERVIES�lER: IF ft0, GO TO QUESTION 15). Yes 12. In the past 12 months, how often did you shoot street drUgs? (INTERVIEk'ER: READ ALL ANSh'ERS) _ Several times a day Once a veek � _ Once a 'day Less than once a veek Several times a veek Never 13. Since January 1978, have you ever used a needle or syringe, that is, ' "vorks", after someone else used it or may have used it? � I—I Ro (INTERVIESIER: IF N0, GO TO QUESTION 15) . Yes 14. In the past 12 months, have you ever used a needle or syringe, that is, "vorks", after someone else used it or may have used it? � I=I No Yes 15. Since January 1978, vere the people you had sex vith: (INTERVIE�lER: BEAD ALL ANSKERS) Only men _ Only Women (INTERVIEKEg: IF ONLY NOMEN, GO TO QUESTION 36) Both, mostly me� Both, mostly vomen Both, about equal During the rest of this intervieW, having sex means having a mari's penis in your vagina, rectum, or mouth. 16. HoW old Were you When you first had sex vith a man? (_�_) Years � 17. Since January 1978, have you had sex vith a man vho was biaexval, that is, a man vho has sex With both men and vomen? Ao Yes Unsure .. .�.:. ., .......,..,_ ,.... ... ... .. . ., ._ , w;:�., . , ' i (�� 18. Since January 19.78, horr many nev sex partners have you had, that is, men with vhom vou had not had sex before? �—�—�—�—� 19 . These questions are about the different kinds of sex you might have had. Since January 1978 , have you ever: Yes Ro had a man put his penis in your vagina had a man put his penis into your mouth had a man put his penis into your rectum _ _ (INTERVIEWER• IF N0, GO TO QUESTION 20) � 20. In the �st 12 months, with how many different men have you had sex? �—�—�_�—� (INTERVIENEB: IF "0", GO TO QUESTION 26) 21. Hov many were neW sex �artners, that is, men vith vhom you had not had � . sex before? �_�_�_�_� 22. In the last 12 months, have you had sex vith someone only one time and never again? I—I �o Yes 23. In the past 12 months, has a man put his penis into your rectura? " I=I No ` °es 24. In the past 12 months, did a man use a rubber or condom While having sex vith you? . No (INTERVIEXER: IF N0, GO TO QUESTION 27). I_I Yes 25. In the past 12 mont?�s, hov often did your steady sex partner use a rubber o�condom? (INTERVIEKER: READ ALL AIiSNERS) • _ Every time Never _ Usually (half the time or more) I_I No steady. sex partner _ Sometimes (less than half the time) 26. In the past 12 months, how often did your other sex partners use a rUbber or condom? (INTERVIENER: READ AI.L ANSFTERS) _ _ Every time Never _ Usually (half the time or more) I_I Ro other sex partners _ Sometimes (less than half the time) 27. Since January 1478, has a man given you money or drugs to have sez? Ro (INTERVIENER: IF R0, GO TO QUESTION 32) . • I_) Yes 28. In the past 12 months, has a man given you money or drugs to have sex? Ao (INTERVIENEH: IF N0, GO TO QUESTION 32). _ I_I Yes � ��i�� . 29. In the Qast 12 months, hov many men have given you noney or drugs for sex? (—�—�—�—� 30. In the past 12 months, vhen a man gave you money or drugs to have sex hou often did (INTERVIENER: READ ALL ANSKERS) _ . . Every Usually Sometimes Never time (half the (less than ' time or more) half the time) he put his penis into your vagina he put his penis into your rectum he put hia penis into your mouth 31. Hov often did he use a rubber or condom? �—, �—� � �_� (_I 32. Since January 1978, have you had sex with anyone who shot street drugs vith needles? No (INTERVIEKER: IF Nd, GO TO QUESTION 35) . Yes � Unlrnorm (INTERVIEKER: IF UNKNOS�7N, GO TO QUESTION 35) . 33. Of the men you had sex With during the past 12 months, horr many shot drugs vith needles? , �—�_�—�—) (INTERVIEI�TER: IF "0", GO TO QUESTION 35) ` 34. Were any of these men your steady sexual partners? I_—I No Yes 35. Have you ever had sex vith a man vho has AIDS or has had a positive blood test for the AIDS virus? No Yes Don't ]rnow 36. Since January 1978 have you used oral contraceptives or birth control pills? I—IRo (INTERVIENER: IF N0, GO TO QUESTIOft 38) Yes 37. Including all the times you took birth control pills since January 1978, What is the total number of months you took the pills? �—�—�—� 38. Are you pregnant noW? . Po I_ Yes �_ Unsure .� � ��s' 39. W'hat racial group do you belor.g to? Do you think of yourself as: 11NTERVIE'rlER: EEAD ALL ANSw�RS) Alasken Native/.4�nericaZ Indian Asian/Pacific Islander Black Hhite . _ Other, race (Specify: ) 40. Are you Spanish or Hispanic? No (INTERVIEXER: IF N0, GO TO QUESTION 42) I_I Yes 41. What is your Spanish/Hispanic origin? Do you consider yourself: (INTERVIEFIER: READ AI,L APISKERS) • Cuban Mexican/Mexica.n American Puerto Rican Other 42. Kere you born in the United States? _ I=IYes (INTERVIEKER: IF YES, GO TO QUESTIOR 45) No 43. In r�hat country vere you born? 44. How old kere you when you first moved to the United States to live? �_�_� Years � 45. Are you living With someone you have aez xith? � I—_I fto Yes 46. FThat is your marital status? Are you nov: (INTERVIEWER: READ ALL ANSNERS) • Married Separated _ Hidowed (_I Never Married � Divorced 47. Khat is the last grade you completed in school? (INTERVIEFlER: PROBE FOR DEGREE) _ Elementary School (Grade 0-8) College Graduate (4-Year Degree) _ Some high school (Grade 9-11) I_I Graduate Nork _ High School Graduate (Grade 12) _ Some College or technical�training (no 4-year degree) This is the last question. Thank you for participating in our survey. Do you have any questions you vould like to ask? . �� . . � -� . �. ________________________________________________________________________________ ____________________________ OPTIONAL QUESTIONS -- Clinica� may choose to add optional qvest:ons to the qvestionnaire depending upon their public health needs and the populations they serve. 1. Since (date survey began in the clinic) have you participated in this survey? No . Yes Don't lrnov 2. Aave you ever had your blood tested for the AIDS virus before? No Yes Don't lrnov � (INTERVIEFTER: IF NO OR DON'T KNON, GO TO QUESTION 6) 3. Flhen Was the test done? Hithin the last 6 months 6-12 months ago _ More than 12 oonths ago 4; Did you get the results of your test? I=I No (INTERVIENEB: IF R0, GO TO QUESTION 6) Yes 5. Khat Was the result of the test? I—_I Positive - Negative 6. Since January 1978, have you had sex vith a man who vas from Haiti? I=) No Yea 7. Since January 1978, have you had sez vith a man vho vas from Africa? I=I No Yes 8. Since January 1978, have you had sex vith a man Who has hemophilia or a + b�eding disorder? I=I No . Yes . ' . ��'i�°�- . (for clinic use) STD diagnoses and/or syu►ptoms at this clinic visjt (check all that apply): _ penile/vaginal discharge ano-genital ulcer _ pelvic inflammatory disease � _ pubic lice ano-genital warts ano-genital herpes non•-gonococcal urethritis _ gonorrhea syphilis chlamydia trichomonas hepatitis B other sesually transmitted infection other IF AVAILABLE: � VDRI./STS/RPB He�titis B antigen/antibody reactive pasitive ' I—) non-reactive - I_I negative i ��"�� .. St. Paul Division of Public Health Room 111 Clinic Exhibit E A Double-Blinded HIV Seroprevalence Survey of Patients Attending Sexually Transmitted Disease Clinics I. Background The MDH is proposing to conduct a double-blinded survey of STD patients at the Room 111 Clinic. The double-blinded method requires that only blood specimens collected for another purpose will be used for HIV antibody testing; blood will not be obtained specifically for HIV antibody testing. Names and other identifying information are removed before the specimen is tested. Identifying information will be de-linked from the specimen at the MDH; the code numbered specimen will be sent for HIV antibody testing at another laboratory. Once the identifying � information is removed, there will be no way to link names with test � results at either the MDH or the Room 111 Clinic. This survey will begin September 1, 1988 and continue until 1,100 specimens have been collected -- approximately November 30, 1988. - II. Goals and Objectives . A. To estimate HIV prevalence in STD clinic patients by age, sex, race, -. county, risk exposure group and reason for clinic visit. B. To monitor trends in HIV infection levels over time. III. Methods A. Inclusion/Exclusion Criteria 1. Serum will be eligible for the survey if it is obtalned from patients 1) at their initial visit for a new disease episode and 2) who have not visited the clinic within the previous 90- day period. 2. Sera from patients making follow-up visits for previously diagnosed disease episodes during the survey period will be excluded. 3. Sera from asymptomatic patients attending the clinic solely for reasons of HIV testing and counseling will be excluded from the survey. B. Enrollment Procedures 1. The clinic will conduct sequential sampling - every specimen . _ that is eligible for the survey will be enrolled. The clinic . should obtain a total of 1 , 100 sera for the survey. 5 i , , ��_�� 2. Clinic staff will examine patient's charts to determine if their sera is eligible for the survey. If eligibility criteria are satisfied: a) a survey form provided by the MDH will be completed by indicating the patient's county of residence, age group, sex, race, risk exposure group and reason for clinic visit (refer to the attached survey form) . b) the standard specimen for syphilis testing will be obtained. c) a code label will be peeled off the survey form and placed on the syphilis serology specimen. d) the specimen will be sent to the MDH serology laboratory for syphilis testing. e) weekly batches of completed survey forms will be sent to ' the MDH, until 1,100 specimens have been received. C. Procedures at MDH 1. Specimens will first be tested for syphilis. A 0.3 to 1 .0 ml aliquot of the specimen will be transfered into another specimen tube. � 2. The al i quoted speci men wi 11 be 1 abel ed wi th a code number and sent for HIV antibody testing at either the American Red Cross, St. Paul Regional Blood Center, or the Memorial Blood Center of Minneapolis. 3. The data from the survey forms will be entered into a computer by code number. 4. In this procedure, the testing laboratory will receive specimens with only a code label on them. MDH personnel will have no way of identifying individuals being HIV antibody tested. IV. Reimbursement The Room 111 Clinic will be reimbursed at a rate of a5.00/survey specimen for each specimen sent to the MDH. V. Analysis and Results �_- The MDH will provide summaries to the St. Paul Division of Public Health and the Room 111 Clinic on a monthly basis for the duration of the survey. A one to two month lag between the start date of the survey and receipt of the first report may occur. The summary will consist of seroprevalence by age, race, gender, sexual orientation, county of . _ residence, risk exposure group and reason for clinic visit. These _ reports will be provided on either computer diskette or paper copy, whichever the� recipient prefers. 6 • � c��- � ,�� DOUBLE BLINDED SURVEY FORM COUMY OF RESIDENCE p� SDC � -1 ❑ ❑ ❑ 1 under 15 1 male 1 White 2 15-19 2 female 2 Black 3 20-24 3 Asian/Pacific islander 4 25-29 4 American Indian 5 30-34 5 Spanish/Hispanic 6 35-39 6 Other 7 40-44 8 over 44 � RISK DCPOSURE GROUPS _ : REASON FOR CLINIC VISIT (mark aIl that apply) (mark all that apply) Q Man who had sex with a man O Follow-up STD visit O Used IV drugs at least once in past year � _ O STD examitreatment Q Sexual partner of above since 1978. Q Referred by HIV + sexual partner Q Sexual partner of above in past year Q Referred by STD sexual partner Q Heterosexual Q Referred by Health DepartmenVHIV Q Exchanged d�ugs/money for sex � Q Referred by Health DepartmenVSTD Q Unknown � PMB/BB/Hosp Referral Q Symptomatic for HIV/AIDS disease Q AsymptomatiGworried about HIV Q Other � Not stated .WHITE — CITV CLERK � �PINK — FINANCE GITY OF SAINT PAUL Counci! Q�.� „ CANARV — DEPARTMENT s BLU�E �� — MAVOR File NO• � i 7a � Council Resolution f �� Presented By �ferred To Committee: Date �d �� Out of Committee By Date WHEREAS, the Mayor, pursuant to Section 10,07.1 of the City Charter, does certify that there are available for appropriation revenues in excess of those estimated in the 1988 budget; and WHEREAS, the Mayor recommends the following changes to the 1988 budget: Current Amended Bud�et Changes Bud� FINANCIAL PLAN GL-126-36023-3699 $20,575 $12,000 $32,575 Heritage Preservation Commission Minnesota Historical Society Grant GL-126-36023-6999 14,142 -0- 14,142 Outside Private Donations/Foundation Grants GL-126-36023-4299 -0- 20,000 20,000 Sale of Marker Plaques GL-126-00000-9802 13,853 -0- 13,853 Reserved for Encumbrances Total Financial Plan $48,570 $32,000 $80,570 COUNCIL MEMBERS Requested by Department of: Yeas Nays Dimond Long in Favor Goswitz Rettman B �be1�� _ Against Y Sonnen Wilson Form Approved by City Attorney Adopted by Council: Date Certified Passed by Council Secretary By— By. A►pproved by �Vlavor: Date _ Approved by Mayor for Submission to Council By By a