Archival Content: 1999-2005

Forms, Logs, and Worksheets

NOTE: All items in brackets are links to indicated page numbers within those documents

Outreach Documentation

• Request for Services [Montrose #5.2.1]

• Outreach Intake Form [Montrose #5.8.1]

• Outreach Daily Briefing and Debriefing [Montrose #5.3]

Referrals

• Outreach Referral Form [Montrose #5.8.2]

• Outreach Referral Form/Formulario de Referencia para el Servicio de Alcance Comunitario [Montrose #5.8.3]

Screening

• Initial Screening Form (English and Spanish) [Montrose #5.4.1 and 5.4.2]

• SAMHSA TIP Manual on screening for substance abuse and infection diseases

Informed Consent and Testing

• Informed Consent for Confidential HIV Test [Montrose #5.5.1]

• Informed Consent for Confidential HIV Test (Sp) [Montrose #5.5.2]

• Outreach Post Confidential Test Counseling Slip [Montrose #5.5.3]

• Informed Consent for Anonymous HIV Test [Montrose #5.5.4]

• Informed Consent for Anonymous HIV Test (Sp) [Montrose #5.5.5]

• Outreach Post Anonymous Test Counseling Slip [Montrose #5.5.6]

• OraQuick Test Results [Montrose #5.6.2]

• OraQuick Client Rest and Result Log [Montrose #5.6.3]

• OraQuick Rapid HIV Testing Guidelines for California: Policies, Procedures and Quality Assurance (PDF)

• HIV rapid testing (OraQuick) Testing Procedures and Quality Assurance for California (MS Word)

• Record of Tuberculin (TB) Skin Testing (Confidential) [Montrose #5.7.1]

• Record of Tuberculin (TB) Skin Testing (Anonymous) [Montrose #5.7.2]

Staff Tracking Sheets (Daily, Weekly, Monthly, Annually)

• Daily field outreach form (MS Excel, 291 KB)

• Daily, weekly contact sheets (MS Excel, 291 KB)

• Monthly contact sheet (MS Excel, 291 KB)

Inventory and Distribution Tracking

• One-to-One Distribution (bleach, condoms, etc.) (MS Excel, 291 KB)

• Mass Distribution (bleach, condoms, etc.) (MS Excel, 291 KB)

• Inventory [AOP]

Vehicles

• Vehicle Check List (MS Excel, 291 KB)

• Vehicle Mileage Log (MS Excel, 291 KB)

Simple Screening Instruments for Outreach for Alcohol and Other Drug Abuse and Infectious Diseases Substance Abuse and Mental Health Services Administration (SAMHSA)

Winters KC, Zenilman JM, Consensus Panel Co-Chairs. Simple Screening Instruments for Outreach for Alcohol and Other Drug Abuse and Infectious Diseases: Treatment Improvement Protocol (TIP) Series 11. Rockville (MD): Substance Abuse and Mental Health Services Administration; 1995. DHHS Publication No. (SMA) 95-3058.

What’s in this manual?

This TIP, one in a series published by SAMHSA’s Center for Substance Abuse Treatment (CSAT), provides information about two screening instruments – one for substance abuse and one for infectious diseases. The manual describes their development and provides guidelines for their use. These screening instruments are designed to link drug-using individuals with HIV/AIDS, TB, and STDs to substance abuse treatment.

How much does the manual cost?

It is available free of charge from SAMSHA.

How can I get the manual?

• Download it from the SAMSHA website

• Order copies from the National Clearinghouse for Alcohol and Drug Information(1-800-729-6686).

For more information about CSAT and SAMHSA

Center for Substance Abuse Treatment
Substance Abuse and Mental Health Services Administration
Rockwall II, 5600 Fishers Lane
Rockville, MD 20857

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