HIV Self Testing Tracker Capture
Complete this tracker capture only after HIV self testing results are confirmed
HIV Self Testing Tracker Capture
Distribution Date
HIV Self Test Distribution Center
Distributed During
- Select a program -
Moonlight
Tertiary Institutions
Outreaches & Exhibitions
Health Facility Reported To
- Select -
Highfield Polyclinic
Western Triangle Satellite
Sally Mugabe Hospital
Rutsanana Polyclinic
Glen Norah Satellite
Glen View Polyclinic
Glen View Satellite
Budiriro Polyclinic
Budiriro Satellite
Kambuzuma Polyclinic
Warren Park Polyclinic
Mufakose Polyclinic
Kuwadzana Polyclinic
Kuwadzana Satellite
First Name
Last Name
Gender
- Select -
Male
Female
Other
Date of Birth
Physical Address
District
- Select -
Harare South Western
Harare West South West
Harare Western
Harare Southern
Phone Number (Indicate Code e.g +263)
HIV Testing History
- Select -
First Time
Retest
HIV Self Test Kit Batch Code
HIV Self Testing Results
- Select -
Reactive
Non-reactive
Inconclusive
Wrong Phone Number
Date of Results
Post-test services referred for
Confirmatory Test
Pre-Exposure Prophylaxis
Post-Exposure Prophylaxis
Condoms
Family Planning Services
Non-clinical services
Post-test services received
Confirmatory Test
Pre-Exposure Prophylaxis
Post-Exposure Prophylaxis
Condoms
Family Planning Services
Non-clinical services
Name of the Distributor
Officer Designation
- Select -
Program Coordinator
Program Assistant
Program Graduate Trainee
Program Intern
Complete Capture
