One on One Circle Model Session Data Form

Instructions

Please read questions carefully as certain parameters must be met prior to moving on to the next question

Question Title

* 1. Select Organization

Question Title

* 2. Date of session

Date / Time

Date

Question Title

* 3. Participant Name or Identifier

Question Title

* 4. Age of participant

Under 18

18-24

25-34

35-44

45-54

55-64

65+

Not provided by participant

Question Title

* 5. Email Address of participant (optional)

Question Title

* 6. How does the participant identify themselves? (select current category)

Patient

Client

Peer

I do not fit into any of these categories (Please explain)

Question Title

* 7. Did the participant receive a HCMSG educational counseling bag?

Yes

No

If 'No' please provide a brief explanation

Question Title

* 8. What is the participants Hepatitis C Status?

Positive

Negative

Not tested

Tested but awaiting results

Previously positive but now cured

Please explain:

Question Title

* 9. The participant was informed of the importance of follow-up after being cured of Hepatitis C

Yes

No

N/A

Other (please specify)

Question Title

* 10. Was stigma addressed?

Yes

No