One on One Circle Model Session Data Form

Instructions

Please read questions carefully as certain parameters must be met prior to moving on to the next question

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* 1. Select Organization

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* 2. Date of session

Date / Time

Date

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* 3. Participant Name or Identifier

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* 4. Age of participant

Under 18

18-24

25-34

35-44

45-54

55-64

65+

Not provided by participant

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* 5. Email Address of participant (optional)

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* 6. How does the participant identify themselves? (select current category)

Patient

Client

Peer

I do not fit into any of these categories (Please explain)

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* 7. Does the participant have access to the internet?

Yes

Other (please specify)

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* 8. How much time during the session was dedicated to Hepatitis C?

0-5 mins

6-10 mins

11-15 mins

16-20 mins

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* 9. How many one on one Circle sessions did this participant attend?

Total number of Circle Sessions

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 10. Was this participant referred by another Circle Model participant?

Yes

If 'No' explain how the participant heard about the Circle Model Session.

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* 11. Did the participant receive HCMSG educational print materials?

Yes

If 'No' please provide a brief explanation

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* 12. Was the participant tested?

Yes because of the Circle Model

No (also if they never were tested at all)

Other: Explain if the participant was tested for Hepatitis C due to other supportive services (other than the Circle Model)

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* 13. Does the participant consider the education and support they received about Hepatitis C and harm reduction in terms of safer drug use practices to be

Effective

Not Effective

N/A

Other: If the participant answered "not effective" provide a reason why.

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* 14. Does the participant consider the education and support they received about Hepatitis C and harm reduction in terms of safer sex practices to be

Effective

Not effective

N/A

Other: If the participant answered "not effective" provide a reason why.

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* 15. The participant was cured of Hepatitis C

Yes

Other (please specify)

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* 16. The participant was informed of the importance of follow-up after being cured of Hepatitis C

Yes

N/A

Other (please specify)