San Angelo AIDS Foundation
Peer Educator Contacts Worksheet

Thank you for responding this week.
Please remember that this form is for evaluation of the program only.
It is not used to evaluate how good or bad you are doing.
It is very important to include exact data.
Continue to get the word out about HIV/AIDS prevention and set your own goals!!


Name: 

Total number of people I talked to this week about HIV/AIDS:
        Number of males: 
        Number of females: 
        Number of people that this was 2nd+ discussion: 
Ages of people I talked with: 10 11 12 13 14 15 16 17
                                                     18 19 20 21 22 23 24 Other
Risk Factors identified:
GLBT  IDU  Drugs/Alcohol  FMS  Sex Worker  Homeless/Runaway
Most of my discussions were related to:
AIDS 101 information
Testing
Condom use
Prevention support
Number of people that condoms were given to: 
Number of people referred to SAAF for HIV testing: 
Number of people referred to SAAF for additional information: 
Number of people referred to somewhere other than SAAF: 
Number of group presentations provided:
        At school 
        At work 
        Other places 
I need help with:

Additional comments:

  

This form created by Shawn Elander, RN for San Angelo AIDS Foundation ©2000.