Circle Model Data Intake Form

The Circle Model provides a non-hostile environment where participants are treated with respect encouraging them to reduce the harm of infection and encourage changes for a healthier lifestyle. Read more here https://www.hepatitiscmsg.org/how-does-the-circle-model-work.html

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* 1. Select your organization

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* 2. Date of session

Date / Time

Date

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* 3. How many attendees were engaged this month using the Circle Model?

Participants

100

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 4. How many have previously attended other Circle sessions?

Participants

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 5. How many new Circle Model participants did you have this month?

Participants

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 6. What percentage of participants received HCMSG Circle Model materials?

100

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 7. What percentage of participants received Educational Counseling Kits?

100

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 8. How many were tested for Hep C?

Participants

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 9. Do you feel the Circle Model contributed to participants getting tested?

Yes

If no, explain.

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* 10. Do you feel the Circle Model contributed to safer drug use practices among participants?

Yes

If no please explain:

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* 11. Do you feel the Circle Model contributed to safer sexual practices among participants?

Yes

If no please explain:

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* 12. Were attendees informed of the importance of follow-up after being cured of Hep C?

Yes

If no please provide a brief explanation

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* 13. How are the participants engaged dealing/coping with stigma?

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* 14. What percentage of your participants this month currently have a support system?

100

Clear

i We adjusted the number you entered based on the slider’s scale.

Circle Model Data Intake Form

Question Title

* 1. Select your organization

Question Title

* 2. Date of session

Question Title

* 3. How many attendees were engaged this month using the Circle Model?

Question Title

* 4. How many have previously attended other Circle sessions?

Question Title

* 5. How many new Circle Model participants did you have this month?

Question Title

* 6. What percentage of participants received HCMSG Circle Model materials?

Question Title

* 7. What percentage of participants received Educational Counseling Kits?

Question Title

* 8. How many were tested for Hep C?

Question Title

* 9. Do you feel the Circle Model contributed to participants getting tested?

Question Title

* 10. Do you feel the Circle Model contributed to safer drug use practices among participants?

Question Title

* 11. Do you feel the Circle Model contributed to safer sexual practices among participants?

Question Title

* 12. Were attendees informed of the importance of follow-up after being cured of Hep C?

Question Title

* 13. How are the participants engaged dealing/coping with stigma?

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* 14. What percentage of your participants this month currently have a support system?

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* 15. What support services will your organization use to address the stigma among the participants engaged this month?