HIV Prevention Referral Guidelines and Toolbox

Michigan Department of Community Health
Division of Health, Wellness and Disease Control
HIV/AIDS Prevention and Intervention Section


July 2007

You will need Adobe Acrobat Reader  to view and download the PDF files linked below.

Entire document with all attachments in one large PDF file.

Links below are to appendices with samples that you can cut and paste content (if you have Acrobat Reader 8.)

Appendix A: Summary of Program Requirements for Referrals for
HAPIS-Funded HIV Prevention Grantees

Appendix B (1): Sample Referral Tools
1. Referral Form (a): Client Referral Form
2. Referral Form (b): Kick Back Card

Appendix B (2)
3. Referral Log
4. Authorization for Release of Information
5. Memoranda of Agreement (MOA) key elements & sample

Appendix C: Sample Process Monitoring and Quality Assurance Tools
1. Sample Process Monitoring Worksheet
2. Sample Quality Assurance Tool: Chart Review Components for Referrals for Prevention and Test Counseling
 

Direct correspondence to Jane Conklin, 109 W. Michigan Avenue, Lansing, Michigan 48913, 517.241.5938, conklinjane@michigan.gov . Materials and information may be freely used for HIV/AIDS programs. Appropriate citation is requested.

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