Universal ID
DataFax Study Number
DataFax Plate Number
Visit Code
Visit Date(mm)
Visit Date(dd)
Visit Date(yy)
Visit Date
Staff ID
Team ID
1. Reason not participate
2. Don't have time
2. Know my CD4 count
2.Don't wish to be tested
2.No draw/take blood away
2. Find topic uncomfrtble
2. Partner not allow it
2. Parent not allow it
2. Breach of confident
2. Other, specify
2. Other, specify text
Staff Signature / Date