How to investigate Adherence to Antiretroviral Treatment ... - INRUD

How to Investigate Adherence to Antiretroviral Treatment in Health Facilities: Adherence Indicators
Table 9. Example of a Completed Exit Interview Form
Home
Print Exit
EXIT INTERVIEWS side 1 Facility Name _____________________
Date Facility #
A B C D E F H I J K L M N
Pt #
Age in
Yrs
Gender,
M / F
Occupation
Normal
activity
Months on
trt.
Cost home
to clinic
Time Home
to clinic (in
mins)
Time in
Clinic today
(in mins)
All ARVS
dispensed
All Non
ARVS
dispensed
All ARVs
well labelled
All other
Meds well
labelled
1 33 M Daily labour No 3 0.65 90 120 Yes Yes No No
2 43 M Employee Yes 4 4 60 150 Yes Yes No No
3 43 M Employee Yes 48 0.65 15 120 Yes Yes No No
4 32 F House wife Yes 12 3.2 90 150 Yes NA No NA
5 25 F House Maid Yes 12 1.5 60 150 Yes Yes No No
6 23 F Student No 12 1 60 120 Yes Yes No No
7 36 F No 12 1.6 30 150 Yes Yes No No
8 44 M Teacher Yes 24 0.65 30 180 Yes NA No NA
9 50 F No 12 0.65 120 120 Yes Yes No No
10 5 M Kinder Garten No 6 1.3 10 180 Yes Yes No No
11 37 M Employee Yes 26 0.65 15 140 Yes NA No NA
12 28 F House wife Yes 18 1.3 60 180 Yes Yes No No
13 8 F Student Yes 6 1.3 60 150 Yes Yes No No
14 28 M Daily labour No 22 1.2 10 180 Yes Yes No No
15 35 F No 18 2.4 120 95 Yes Yes No No
16 37 F No 5 7.2 150 240 Yes Yes No No
17 40 F No 36 3.6 60 120 Yes Yes No No
18 40 F No 15 1.2 30 60 Yes Yes No No
19 28 M Employee Yes 12 2 45 175 Yes NA No NA
20 34 F Yes 12 2.25 45 190 Yes NA No NA
21 40 F Yes 6 1.75 45 180 Yes Yes No No
22 50 F Employee Yes 7 0.65 15 180 Yes NA No NA
23 9 F Student Yes 6 3 90 100 Yes Yes No No
24 33 F Yes 7 1.3 15 180 Yes Yes No No
25 38 F Employee Yes 3 2.8 45 180 Yes Yes No No
26 39 F Employee Yes 6 0.65 15 180 Yes NA No NA
27 26 F Employee Yes 7 1.3 30 120 Yes Yes No No
28 29 F Yes 15 1.2 20 60 Yes NA No NA
29 25 F Yes 12 0.65 15 90 Yes NA No NA
30 38 M Yes 8 0.65 15 120 Yes Yes No No
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