STIs 5: Partner Notification/Referral Cards

Partner Notification/Referral Cards

Sample 3: Contact Tracing Card Used in Zimbabwe

Front of card:

File Copy

No. ____

_______________________________________
(Name of health institution)

Contact name _____________________________ M F

Address _________________________________

Area ___________________________________

Introducer name (index) ____________________ M F

Code 1 2 3 4 5

6 7 8 9

Issuing clinic _________________________________

Date ______________________________

Back of card:

Outpatient Clinic Card

When this card is brought to your clinic, please confirm that the name and address of the person bringing it corresponds with the name and address on the other side.

Then complete the date of first attendance and the name of the clinic attended:

Date __________

Clinic attended _____________________________

If this card is handed in at a clinic outside of ___________ please forward to

________________________________________
(Name and address of health institution)

Adapted from Control of Sexually Transmitted Diseases: A Handbook for the Design and Management of Programs. G. Dallabetta, M. Laga, and P. Lamptey, eds. AIDSCAP/Family Health International, 1996.