File:  EBBA-E


1.       I need to know your name so that I can check to see if your name is on the parent decline list.

2.       Confidentiality Statement:  I need to record information onto this questionnaire in order to keep data for evaluation of this program.  I want to emphasize that no names are being kept on the questionnaire.

3.       Descriptive information:         [  ] Male                        [  ] Female        Age:                

Ethnic background:        [  ] Black           [  ] Hispanic       [  ] White

                                          [  ] Asian or Pacific Islander

                                          [  ] American Indian or Alaskan Native

                                          [  ] Other:                                             

4.       Review of How To Use A Condom brochure.  (Abstinence statement, condom selection, correct condom usage and resources/test sites.)

5.       Review the HIV, Exposure Risk Assessment and discuss any concerns, as appropriate.

6.       Review of ways to avoid HIV exposure:

a.        Abstain from sexual intercourse

b.        If you don't abstain, then:

1.       limit the number of sexual partners

2.       use a condom every time you have sex

3.       communicate with your partner

c.        Avoid use of illegal drugs, particularly injecting drugs intravenously

7.       Discuss any other questions or health concerns.

8.       How do you feel about this interview/process?

a.        What could we do differently?

b.        Handouts


[  ]  Distributed Condom(s)

[  ]  Referral Initiated To:

      [  ]  School Nurse     289-3111 x146

      [  ]  Community Health Services        289-1086

[  ]  Other                                                                     

[  ]  Initial Visit               [  ]  Repeat Visit

Faculty Advisor:                                                               Date:                                                 

Revised:  8/25/92

ACSD 14, Colorado