UNIFORM REPORTING SYSTEM PREVENTION SERVICES
INDIVIDUAL LEVEL INTERVENTION FORM * BOLD FIELDS MUST BE COMPLETED
* ID: _______________________
* CLIENTS NAME: ____________________________ ____________________________ _____________ * LAST
* FIRST
* ACTUAL DATE: __ __ / __ __ / __ __ __ __ MONTH
DAY
Encounter With:
YEAR
100 Client
Middle
Actual Location: 01 Office Based Visit
02 Home Based Visit
200 Client Representative Or Collateral
03 Hospital Visit
04 Field Visit
99 Other
300 Others On Behalf Of Client * STAFF:
* PROGRAM: WBA (CDC/RW)
* SERVICE SITE: * ENCOUNTER:
* SERVICE(S) PROVIDED:
01 SINGLE SESSION STRUCTURED INTERVENTION (Curriculum Based Intervention & Client Level Data Gathered)
05 HIV, STD, AND SUBSTANCE USE EDUCATION
02 MULTIPLE SESSION STRUCTURED INTERVENTION (Curriculum Based Intervention & Client Level Data Gathered)
05 HIV, STD, AND SUBSTANCE USE EDUCATION
03 INDIVIDUAL RISK REDUCTION COUNSELING (Non-Curriculum Based Intervention & Client Level Data Gathered)
06 HIV, STD, AND SUBSTANCE USE RISK REDUCTION COUNSELING
How Service Provided: Location:
01 Direct Provision
02 Advocacy
03 Counseling To Client
01 Office Based Visit
02 Home Based Visit
03 Hospital Visit
04 Referral 04 Field Visit
99 Other
Outcome: 01 Service Need Still Pending, Requires Follow-Up 02 Service Need Resolved 03 Issue Unresolved, Requires Follow-Up
04 Issue Resolved, No Follow-Up 05 Unknown 19 Confirmed Appointment
20 Contact Has Not Seen Client 21 Counseling Completed 22 Follow-Up Required
23 Follow-Up Completed 24 Incentive Given 25 Information Given
Topics (Please Circle All That Apply): Availability / Disposal of Syringes
Negotiation Of Safer Sexual Behaviors
Psychological Issues
Condom Use
Partner Notification / Disclosure
Risk Reduction Strategies For IDUs
100 Medical 101 Health 102 Dental 120 Specialty Medical Care 130 Legal - Guardianship / Custody 150 Legal - Discrimination 160 Legal - Wills / Proxy
170 Legal - Criminal Justice 180 Legal - Immigration / Naturalization 190 Education 191 Employment 200 Alcohol Use 210 Substance Use
Social Issues
Problems Identified (Please Circle or Check All That Apply): 230 Financial / Entitlements 240 Mental Health / Psycho-Social 250 Child Care 260 Domestic Violence 270 Housing 280 Food / Nutrition
290 Clothing 300 Transportation 400 Advocacy 500 General Supportive Service Needs 600 Risk Reduction / Risk Behaviors 700 Family Issues
Collaterals Involved - Please Print (Please See URS Collateral Form): __________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________
PLEASE COMPLETE THE URS REFERRALS INFORMATION FORM FOR REFERRALS MADE AND THE URS HIV / AIDS RISKS HISTORY FORM FOR HIV / AIDS RISKS Progress Notes / Remarks:
New York State Department of Health, AIDS Institute, Systems Development
* MS WORD*
revised April 2004 (URS v4.1c)
New York State Department of Health, AIDS Institute, Systems Development
* MS WORD*
revised April 2004 (URS v4.1c)