FY19 Subsequent Visits Survey

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Survey conducted on visits after the initial visit

Member ID (First Initial of First, First Initial of Last Name, Birthday MM/DD/YYYY - EXAMPLE - BP02091986) *

Zip Code *

Drug of Choice *

Heroin

Cocaine

Methamphetamine

Fentanyl

Suboxone

Oxycodone

Other:

Required

Number of Syringes Collected *

Number of Syringes Provided *

How many times do you inject per day? *

HIV Testing done today? *

Yes

Other:

HEP C Testing done today? *

Yes

Other:

HEP B Testing done today? *

Yes

Other:

Hepatitis A Vaccine? *

Recieved Today

Declined

Already Recieved

Referred to Treatment *

Yes

Other:

Referrals Made?

Submit

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