HIV Treatment Facility Assessment Form
Use this form to assess the services, staffing, patient flow, medication access, testing and monitoring practices, referral pathways, recordkeeping, and follow-up processes of an HIV treatment facility.
Which HIV treatment services are provided at this facility?
*
Antiretroviral therapy (ART)
HIV counseling and testing
Prevention of mother-to-child transmission (PMTCT)
Opportunistic infection management
Adherence support
Other
How would you rate the adequacy of facility staffing for HIV treatment services?
*
Inadequate
1
2
3
4
Fully adequate
5
1 is Inadequate, 5 is Fully adequate
What is the average patient wait time from arrival to consultation?
*
Less than 30 minutes
30–60 minutes
1–2 hours
More than 2 hours
Rate the facility's access to essential HIV medications.
*
Very poor
1
2
3
4
Excellent
5
1 is Very poor, 5 is Excellent
Which testing and monitoring services are available on-site?
*
CD4 count
Viral load testing
Hepatitis screening
Tuberculosis screening
Other
How are referrals to other health services managed?
*
Formal written referral system
Verbal referrals only
Electronic referral system
No formal referral process
Please rate the quality of medical recordkeeping at the facility.
*
Very poor
1
2
3
4
Excellent
5
1 is Very poor, 5 is Excellent
Which follow-up processes are routinely implemented for patients?
*
Scheduled follow-up appointments
Telephone reminders
Home visits
Community health worker outreach
Other
Please rate the overall quality of HIV treatment services at this facility.
*
1
2
3
4
5
Additional comments or suggestions regarding the facility’s HIV treatment services.
Submit Assessment
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