Universal ID
DataFax Study Number
DataFax Plate Number
Visit Code
Enrollment Date(mm)
Enrollment Date(dd)
Enrollment Date(yy)
Enrollment Date
Staff ID
Team ID
1. Mo/Yr dx with HIV
1. DK / REF
2. HIV-rel med care?
3. Last visit health fac.(mm)
3. Last visit health fac.(dd)
3. Last visit health fac.(yy)
3. Last visit health fac.
3. Health fac DK/REF
4. Blood test for CD4?
4a. CD4 count
4a. CD4 count DK/REF
4b. When rcv CD4 result
4b.When receive DK/REF
5. Should take ART?
6. Currently pregnant?
6a. How many months?
6a. Mo pregnant REF
6b.Meds prevent transmssn
7. Currently taking ARV?
7a. Ever taken ARV?
7a1. Reason stopped ARV
8. When start ARV?
8. Start ARV DK/REF
9. When refill ARV?
9. Refill ARV DK/REF
10. See your booklet?
10a.Last visit HIV clinic(mm)
10a.Last visit HIV clinic(dd)
10a.Last visit HIV clinic(yy)
10a.Last visit HIV clinic
10a. Visit not written
10b.booklet indicate ever
10b1. Date ART started(mm)
10b1. Date ART started(dd)
10b1. Date ART started(yy)
10b1. Date ART started
10b1. ART not written
10c.Most recent CD4 count
10c.CD4 count not written
10d. Date most recent ART(mm)
10d. Date most recent ART(dd)
10d. Date most recent ART(yy)
10d. Date most recent ART
10d. CD4 test not written
11. See antenatal card?
11a. Last visit antenatal(mm)
11a. Last visit antenatal(dd)
11a. Last visit antenatal(yy)
11a. Last visit antenatal
11a. Date not documented
11b.How many times PMTCT
11c.Currently taking ARV
already attending clinic
refused referral
12. TubeCD4 collected?
12. CD4 Alt Coll Date(mm)
12. CD4 Alt Coll Date(dd)
12. CD4 Alt Coll Date(yy)
12. CD4 Alt Coll Date
13. LT storage collected?
13. LT stor Alt Coll Date(mm)
13. LT stor Alt Coll Date(dd)
13. LT stor Alt Coll Date(yy)
13. LT stor Alt Coll Date
14. Consent return CD4
15.Consent for LT storage
16.Consent future contact
Staff Signature / Date