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KAIS 2007 1 - Kenya National AIDS & STI Control Programme ...

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Figure A5.c Sample laboratory test results form, <strong>2007</strong> <strong>KAIS</strong>.*To be completed by NPHLS*Province:…………………NASCOP AND NPHLS – <strong>2007</strong> <strong>KAIS</strong> LAB TEST RESULTS*District : ……………… *Cluster No: ………….……*Dates of sample collection: From dd……./mm…………/<strong>2007</strong> to dd………./mm…………/<strong>2007</strong>Name of health facility……………………… Health facility Code …... (to be completed by HW)*Checked: Date: dd……….. /mm……… /<strong>2007</strong>*Sign:………………………………………*Missing Code: 01-Participant provided DBS only 02-Rejected/invalid specimenspecimen03-Missing specimen 04-Insufficient** Referral Code: 01-Comprehensive care centre/ART 02-<strong>STI</strong> clinic 03-TB clinic 04-VCT centre 05-PMTCT/antenatalclinic 06-Other (specify in space provided – do not use abbreviations) 07-Respondant received condomNo. IDNOHIV CD4(cells/µl)SYPHSV2Reasonformissingtest result(Entercode*)Resultscollected byIndividual/CoupleI/CSexM/FReturned resultsEnter date(dd/mm/yy) &tick resultsreturned beloweach testReferral(Entercode**)Healthworkercode1 01234 Pos 180 Neg Neg C-03 M 13/10/<strong>2007</strong> 01, 07 5552 01235 Neg - Neg Neg I F 25/10/<strong>2007</strong> 05 5553 01236 Neg - Neg Neg C- 01 F 13/10/<strong>2007</strong> 02, 07 5554………20Remarks…………………………………………………………………………………..…………………………………………………………………………………………………………………………………………………………………………………………(To be completed by the PASCO)Checked: Date: dd………mm………...<strong>2007</strong> PASCO Code: …..…………<strong>KAIS</strong> <strong>2007</strong> 297

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