Circle Model Data Intake Form

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* 1. Select your organization

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* 2. Date of session

Date / Time

Date

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* 3. How many attendees were present at the Circle session?

Participants

100

Clear

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

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* 4. How many have previously attended other Circle sessions?

Participants

Clear

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

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* 5. How many were referred by current/previous attendees?

Participants

Clear

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

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* 6. Did attendees receive incentives to attend?

Yes

If no please provide a brief explanation

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* 7. Did attendees receive HCMSG hygiene kits?

Yes

If no please provide a brief explanation

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* 8. How many have already been tested for Hep C?

Participants

Clear

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

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* 9. How many were tested for Hep C because of the Circle Model?

Participants

Clear

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

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* 10. How many report safer drug use practices after the Circle Model Session?

Clear

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

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* 11. How many reported safer sex practices after attending the Circle Model Session?

Participants

Clear

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

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* 12. How many were cured of Hep C?

If more than 10 participants were recorded please enter the number below

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* 13. Were attendees informed of the importance of follow-up after being cured of Hep C?

Yes

If no please provide a brief explanation