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

Question Title

1. Select Organization (Required.)

Question Title

2. Date of session

Date / Time

Date

Question Title

3. Participant Name or Identifier (Required.)

Question Title

4. Age of participant (Required.)

Under 18

18-24

25-34

35-44

45-54

55-64

65+

Not provided by participant

Question Title

5. Email Address of participant (optional)

Question Title

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

Patient

Client

Peer

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

Question Title

7. Did the participant receive a HCMSG educational counseling bag? (Required.)

Yes

If 'No' please provide a brief explanation

Question Title

8. What is the participants Hepatitis C Status? (Required.)

Positive

Negative

Not tested

Tested but awaiting results

Previously positive but now cured

Please explain:

Question Title

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

Yes

N/A

Other (please specify)

Question Title

10. Was stigma addressed?

Yes

One on One Circle Model Session Data Form

Instructions

Question Title

* 1. Select Organization (Required.)

Question Title

* 2. Date of session

Question Title

* 3. Participant Name or Identifier (Required.)

Question Title

* 4. Age of participant (Required.)

Question Title

* 5. Email Address of participant (optional)

Question Title

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

Question Title

* 7. Did the participant receive a HCMSG educational counseling bag? (Required.)

Question Title

* 8. What is the participants Hepatitis C Status? (Required.)

Question Title

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

Question Title

* 10. Was stigma addressed?

1. Select Organization (Required.)

2. Date of session

3. Participant Name or Identifier (Required.)

4. Age of participant (Required.)

5. Email Address of participant (optional)

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

7. Did the participant receive a HCMSG educational counseling bag? (Required.)

8. What is the participants Hepatitis C Status? (Required.)

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

10. Was stigma addressed?