APPENDIX J: SAMPLE FORMSFirst letter of clients’ first name Day of the month of birthdate Add letter “S” for Streetwork Have you used syringe exchange before? _____ How do you

APPENDIX J: SAMPLE FORMSENROLLMENT/INTAKE/ASSESSMENT FORMS

A) WASHINGTON HEIGHTS CORNER PROJECT, NEW YORK, NY

This document may contain information that is PRIVILEDGED AND CONFIDENTIAL AND EXEMPT FROM DISCLOSURE and it is intended for CaseManagement use by the Washington Heights CORNER Project ONLY. This document is not to be copied or reproducing in any way, anyduplication is strictly prohibited. Thank you.

PARTICIPANT INTAKEDate:___________________

Participant Name:____________________________________________ AKA: _______________________________

Participant ID:_________________ Date of Birth: _________________ Social Security: ______________________

Gender: __________________ Race/Ethnicity: _______________________________________________________

Languages Spoken: ______________________________________________________________________________

Client Referral Source:______________________________________ _____________________________________

Other Services Received at Present:_________________________________________________________________

______________________________________________________________________________________________

Emergency Contact: ______________________________________ Relation: _______________________________

Telephone #: _______________________________________

Health Insurance: __________________________________ ID # ______________________________ Seq. _______

Benefits Received at Present:________________________________________________________________________

Physical Description: _____________________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

Present Housing Situation, History and Needs: _________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

Substance Use History Frequency of use; type of drugs used; routes of administration; previous treatment if any:

_______________________________________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

History of Psychiatric Needs: _______________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

Low-Threshold Enrollment Form

ALL SECTIONS IN BOLD ARE REQUIRED-- Please print legibly

Date: _______________________

First Name: ________________________ D.O.B. ___________________

Race/ Ethnicity: __________________ Language(s): __________________

Housing Status: _______________________________________________

Zip Code where participant sleeps most of the time: ___________________

Drug of Choice: _______________________ Years Injecting: ____________

Drugs Used: ___________________________ Frequency of Use : _______

Where are you currently getting syringes (if anywhere)?__________________

Do you have Medicaid/ Health Insurance? ____________________ PCP: Y / N

Have you had an HIV/HCV test in the last 6 months? Y / N

Where did you hear about WHCP? ___________________________________

CARD CODING INSTRUCTIONS: 1. First letter of participant’s last name: _______ 2. First letter of participant’s first name: _______ 3. Two digit day of birth: _______ 4. Last two digits of participant’s year of birth: _______ 5. Self-identified gender (M/F/T): _______

PARTICIPANT CODE:

ENROLLMENT DISCUSSION POINTS

WHCP provides case management services, HIV/HCV testing, Overdose Prevention training (NARCAN), condoms and safer sex supplies and all resources for safer injection/safer smoking (e.g. syringes, cookers, cottons, chore boy, stem tips, condoms, etc) to all WHCP participants.

Are any of these services of interest to you? Y / N

If so, which ones? Write in below

Notes:________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Enrolling Staff Member: ________________________________

Washington Heights CORNER ProjectSyringe Exchange Participant Enrollment Form Please print legibly

Date: _______________________

First Name: ________________________ D.O.B. ___________________

Race/ Ethnicity: __________________ Language(s): __________________

Housing Status: _______________________________________________

Zip Code where participant sleeps most of the time: ___________________

Drug of Choice: _______________________ Years Injecting: ____________

Drugs Used: ___________________________ Injection Frequency: _______

OPTIONAL INFORMATION Medicaid/ Health Insurance _____________________________ PCP: Y / N

Where does client obtain syringes? __________________________________

Where did client hear about WHCP?_______________________________CARD CODING INSTRUCTIONS:

1. First letter of participant’s last name: _______ 2. First letter of participant’s first name: _______ 3. First letter of participant’s mother’s first name: _______ 4. Last two digits of participant’s year of birth: _______ 5. Self-identified gender (M/F/T): _______

CARD CODE:

ENROLLMENT DISCUSSION POINTS WHCP SEP Operations and procedures Importance of returning used syringes to exchange Legal rights as an SEP participant WHCP Adjacent services available to SEP participants Overdose prevention assessment and information provision HIV and Hepatitis transmission education/ sharing concerns

Notes:_____________________________________________________

__________________________________________________________

Enrolling Staff Member: ________________________________

B) CHICAGO RECOVERY ALLIANCE, CHICAGO, IL

C) MINNESOTA AIDS PROJECT, MINNESOTA, MN

Mainline Assessment Form

Date: ____/____/____ Mainline Code: ______________

Have you used injection equipment in the past 12 months? YES NO

If yes, have you shared syringes with anyone? YES NO

If yes, how many people have you shared with? _________

Do you know how to properly clean a syringe? YES NO

Do you know about the Pharmacy Access Law? YES NO

How many sexual partners have you had in the past 12 months? _________

How often do you use condoms or latex barriers? Always Usually Sometimes Never

Have you ever had an HIV antibody test? YES NO

What was the result of your most recent HIV test? Poz Neg Unsure Decline

If Neg…How often do you test for HIV? 3-6 Months 6-12 Months 12 or More

If Poz… Would you like assistance connecting to HIV services? YES NO

Have you ever had a Hepatitis C test? YES NO

What was the result of your most recent Hepatitis C test? Poz Neg Unsure Decline

Have you been vaccinated for Hepatitis A+B? YES NO Unsure

Zip Code: ___________

Age: 13-18 19-24 25-34 35-44 45+

Gender: Male Female Transgendered

Ethnicity: Hispanic or Latino Not Hispanic or Latino

Race: Caucasian African American/ Black American Asian Native American Other Native Hawiian or Pacific Islander

Staff: _______________

Streetwork Syringe Exchange Enrollment Form Date: __________ Staff Member: ______________________

Client name _________________________________________

Demographics:

Gender: (circle one) F Trans F Trans M M Other ______________ Ethnicity: (circle one) Latino White Af-Am Asian/PI Nat AM Other ____________D. o. B. ___________ Years injecting ___________ Age of first injection __________ Average frequency of injection ___________________

Card Code: ___ ___ ___ ___ ___ ___ Code instructions: first 2 letters of clients’ last name First letter of clients’ first name Day of the month of birthdate Add letter “S” for Streetwork

Have you used syringe exchange before? ___________ How do you get syringes? _________________________________________________

Vein Care(If appropriate, look at injection sites with client to assess for vein damage, developing abcesses, etc).

___Wash Hands ___Rotating injection sites to avoid scarring and damage ___Having enough syringes for a new, sterile syringe for every shot to avoid vein damage ___Veins vs. arteries and what to do if you hit an artery ___Cleaning injection site with soap and water/alcohol pads (spiral or outward motion) ___15 % angle ___Toward the heart ___Inject above the last site to avoid loosening clots. ___Missed shots and abcesses ___What to do if you miss a shot. (Return shot to cooker , use a new syringe, don’t reheat (to avoid injecting coagulated blood)

C) SAFE HORIZON

SYRINGE TRANSACTION FORMS


WHCP Syringe Exchange Transaction Log PLEASE PRINT LEGIBLY

Date: ____________ Loc: __________________ Time Start: _______ Time End:_______

Worker(s):_______________________________________________ SEP/PDSE

SEP Code: Contingency Report: Y / N

New Client Reason for CC: ________________________

Needles In: _______ Needles Out: _________ Condoms (# & Type): __________________

IDU Kits ______ Smoking Kits ______ Gauze Kits _______ Hygiene _______ FK _______

IDI: Bupe OD HCV Details: _______________________________________

Notes/ Edu Sessions/ Referrals _______________________________________

_____________________________________________________________________________

_____________________________________________________________________________







_____________________________________________________________________________

_____________________________________________________________________________







_____________________________________________________________________________


Understanding CRA’s Participant Code

This code is created for all participants in CRA’soutreach who are exchanging syringes. It is uniqueand reproducible but will not identify someone. It isan anonymous code.

Having a card which matches one’s identity conveyslegal exemption to the Hypodermic Syringes andNeedles Act (720 ILCS 635 et seq.) and the DrugParaphernalia Control Act (720 ILCS 600 et seq.) dueto the research conducted as part of our work.

CRA maintains no information on any participantwhich would identify them -- thus the anonymity ofthis participant code is assured.

Below is a key to making, reproducing or matching aseven character participant card to a person:

_____ _____ _____ _____ _____ _____ _____

F or M 1st month of birth day of birth 1stfor letter (01 = January, (01-31) letterMale/ of 12 = December) ofFemale first mother’s

name firstname

Please page Dan Bigg with questions at 312-953-3797 [email protected]

C) MINNESOTA AIDS PROJECT, MINNESOTA, MN

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Sheet

E) HOMELESS YOUTH ALLIANCE, SAN FRANCISCO, CA

SFNE STAT SHEET

DATE: ______________ DAY: _______________ STAFF: ________________

__________________

__________________

__________________

IN OUT m f tg #’s x 4

age ethnicity Sex orient

new drug other

1234567891011121314151617181920212223242526272829303132

F) BALTIMORE NEEDLE EXCHANGE

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CONTINGENCY CONTRACTING FORMS

A) STREETWORK LOWER EAST SIDE, NEW YORK, NY

Streetwork Lower East Side Peer Delivered Syringe Exchange Transaction Log

PLEASE PRINT LEGIBLY

Date: _____________________________ Day (circle one): Sun M T W Th F Sat

SEP Code:

Contingency Contracting ? Y NContingency Contracting Reasons: Cirlce as many as apply

1. Homelessness 7. long travel distances 2. Marginally Housed (any transitional housing) 8. Disposed of syringes- hiding use 3. Police- fear of arrest 9. injecting more frequency 4. Police- conducting neighborhood sweeps 10. Fearful- drug induced paranoia 5. Police- syringes confiscated 11. Other 6. Leaving for extended period

Needles In: _______ Needles Out: _________ Condoms: ______________

Safer Shooting supplies ______ Stem Kits ______ Hygiene stuff ________

Split kits _______ Food ________ Lube _________ Sharps ___________

Notes: _______________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

Streetwork Lower East Side Peer Delivered Syringe Exchange Transaction Log

PLEASE PRINT LEGIBLY

Date: _____________________________ Day (circle one): Sun M T W Th F Sat

SEP Code:

Contingency Contracting ? Y NContingency Contracting Reasons: circle as many as apply

1. Homelessness 7. long travel distances 2. Marginally Housed (any transitional housing) 8. Disposed of syringes- hiding use 3. Police- fear of arrest 9. injecting more frequency 4. Police- conducting neighborhood sweeps 10. Fearful- drug induced paranoia 5. Police- syringes confiscated 11. Other 6. Leaving for extended period

Needles In: _______ Needles Out: _________ Condoms: ______________

Safer Shooting supplies ______ Stem Kits ______ Hygiene stuff ________

Split kits: _______ Food: ________ Lube: _________

Notes: _______________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

SERVICE/REFERRAL FORM


*Education* *Respect*

This document may contain information that is PRIVILEDGED AND CONFIDENTIAL AND EXEMPT FROM DISCLOSURE and it is intended for CaseManagement use by the Washington Heights CORNER Project ONLY. This document is not to be copied or reproducing in any way, anyduplication is strictly prohibited. Thank you.

CLIENT REFERRAL

Date:___________________

Participant Name:___________________________________________

Soc. Sec.#__________________________________ DOB:______________________________

Agency: _________________________________________ Contact: ______________________________

Address: ________________________________________________________________________________

This letter serves as an opportunity to introduce our client who is being referred for

____________________________________. Your assistance in serving our client is greatly appreciated. If

you have any questions regarding this referral or about our program, please call 212 923 7600.

Consent for Release of Information

I, ___________________________________ , give consent for Washington Heights CORNER Project to

release information to ________________________________________ and for ___________________

_____________________ to release information to Washington Heights CORNER Project.

_____________________________________________ __________________________Participant Signature Date

_____________________________________________ __________________________WHCP Staff Signature Date

Washington Heights CORNER ProjectJamie Favaro, Executive Director

76 Wadsworth Avenue, New York, NY 10033Ph: (212) 923 7600 Fax: (212) 923 3576

www.cornerproject.org

*Education* *Respect*

This notice accompanies a disclosure of information concerning a client in alcohol/drug abuse treatment, made to you with the consent of suchclient. This information has been disclosed to you from records protected by Federal Confidentiality rles (4 2 CTR Part 2). The Federal rulesprohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent ofthe person to whom it pertains. A general authorization fo the release of medical or other information is NOT sufficient for this purpose. TheFederal rules restrict any use of this information to criminally investigate or prosecute any alcohol or drug abuse patient.

CLIENT REFERRALDate: _______________________

I hereby give permission for __________________________________ to release information from myrecords to Washington Heights CORNER Project and concurrently give permission for Washington HeightsCORNER Project to release information from my records to ___________________________________ , forthe purpose of REFERRAL OF CLIENT TO DRUG and/or ALCHOHOL TREATMENT, TREATMENTCOORDINATION AND FOLLOW UP.

The following information may be disclosed:

Client psychosocial history, psychiatric evaluation

Medical history, medication regimen

Program attendance, progress in treatment, reason and date of termination

Treatment plan and referrals from treatment

I understand that I can withdraw my consent in writing at any time. Following withdrawal of consent, nofurther information will be disclosed. This permission to release information will expire in 6 months fromthe date of signing.

___________________________________ ___________________________________Client Name Client Signature

___________________________________ ___________________________________DOB Soc. Sec.#

___________________________________ ___________________________________WHCP Case Manager WHCP Case Manager Signature

Washington Heights CORNER ProjectJamie Favaro, Executive Director

76 Wadsworth Avenue, New York, NY 10033Ph: (212) 923 7600 Fax: (212) 923 3576

www.cornerproject.org

B) CHICAGO RECOVERY TRANSACTION MANUAL

EMPLOYEE GUIDANCE FORMS

A) HOMELESS YOUTH ALLIANCE, SAN FRANCISCO, CA


Documents

APPENDIX J: SAMPLE FORMSFirst letter of clients’ first name Day of the month of birthdate Add letter “S” for Streetwork Have you used syringe exchange before? _____ How do you