HIV/AIDS Bureau - Evaluation Interview Forms

Tools for Grantees: Sample Interview Forms

To Order: Email Sandy Chornesky with your name, mailing address and the name of the form(s) you wish to order (ie. Form A-1).


Adherence Support and Evaluation
	To download the cross-site client-level data collection tools and qualitative/site assessment data collection tools please visit the Center for Adherence Support Evaluation website at the NY Academy of Medicine.

Incarcerated Populations
	There are two versions of the baseline interviews, one for jail inmates and one for prison inmates.

B-1	Baseline Interview (JAIL Version)
B-1A	Baseline Interview (Prison Version)
B-2	Inside Facility Event Form
B-3	Staff Report at Release
B-4	Post-Release Services/Status
B-5	Post-Release Interview
B-6	HIV treatment, case management & discharge planning
B-7	HIV Prevention/Education Programs (Single and Multiple Sessions)
B-8	Peer Educator Training Process Data Report
B-9	Disease Screening
B-10	Corrections and Community Based Organization Staff Training

Palliative Care
	Palliative Care Form for HIV measures client & staff outcomes measures client and staff outcomes through a series of tested measures.
C-1	Initial Client Demographics/Initial Client HIV Status
C-2	Initial Alcohol & Drug Treatment History / Initial Mental Illness & Treatment History
C-3	Palliative Care Outcome Scale (Client)
C-4	Missoula-Vitas
C-5	Mental Health Inventory
C-6	Memorial Symptom Assessment Scale (rev)
C-7	Rapid Disability Rating Scale (Client)
C-8	Service Need and Utilization (Client)
C-9	Palliative Care Outcome Scale (Staff)
C-10	Rapid Disability Rating Scale (Staff)
C-11	Service Need & Utilization (Staff)