Participant No: _ _ _ _ _ Survey No: RT__:20__

Human Immunodeficiency Virus Serology

Please print the document labelled ‘Clinical Notes & Test Instructions’ at the top of this module list for details of specimens to test. Enter your results at the RCPAQAP Serology website http://www.rcpaqap.com.au/serology > ‘Direct Data Entry’ Clerical Error Clerical errors are occasionally included in questionnaires. Please circle the specimen and tick the appropriate demographic data that has the clerical error. Specimen:

A,

B (circle)

First Name

Last Name

Kit Information  

Please supply kit lot number and expiry date (Please write expiry date as Mmm/yy example, Nov 17) If you have changed kits since the last RCPAQAP Serology survey, OR have not previously supplied your kit details to the RCPAQAP Serology , please provide us with your new kit details

Test Results  Units – for example, S/CO  Cut-off value is the absolute value that designates the cut-off point below which is negative or equivocal, and above or equal to is low positive or positive. Do not use >, ≥, ≤, < for cut-off value.  Enter N/A (not applicable) if any of the above do not relate to your test – for example, a latex agglutination test HIV Ag/ Ab Combination Testing HIV Ag/Ab Combination (Screening Assay) Kit Lot No: Kit Expiry Date: Specimen No. __A Cut-off: , ≥, ≤,

Value Ag

Circle test result N E P N

E

P

Units:

HIV Ag/Ab Combination (Supplementary Test) Kit Lot No: Kit Expiry Date: Specimen No. __A

Value Ab

__B (do not use >, ≥, ≤,

Value Ag

Circle test result N E P N

E

P

Cut-off: Units: , ≥, ≤, , ≥, ≤, , ≥, ≤, , ≥, ≤, , ≥, ≤,