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Run: Harm Reduction Syringe Services Encounter Log

Track each syringe services encounter in one place, including exchange counts, naloxone, wound care, referrals, and first-visit demographics. Built for SSP s...

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Encounter Identification

Date of Encounter (required)

Date this visit occurred.

Time of Encounter

Approximate time of visit (optional; required by some state reporting systems).

Service Site / Location (required)

Select the site or mobile unit where services were provided.

Other Site Description

Participant Anonymous Code (required)

Enter the participant's unique anonymous identifier (e.g., first two letters of mother's first name + birth month + birth year). Do NOT enter name or full date of birth.

Visit Type (required)

Is this the participant's first visit to this program, or a return visit?

Staff Initials / ID (required)

Initials or staff ID of the SSP worker completing this log.

Syringe Exchange

Syringes Returned by Participant (required)

Total number of used syringes returned at this visit. Enter 0 if none returned.

Syringes Distributed to Participant (required)

Total number of new syringes provided at this visit.

Gauge / Size(s) Distributed

Select all gauge sizes distributed (optional; include if tracked by your program).

Ancillary Supplies Provided

Select all additional harm reduction supplies distributed at this encounter.

Naloxone Services

Was Naloxone Provided? (required)

Naloxone Formulation(s) Dispensed (required)

Select all formulations provided at this encounter.

Number of Naloxone Kits / Units Dispensed (required)

Overdose Recognition and Response Education Provided? (required)

Did staff provide verbal or written overdose education (signs of overdose, rescue breathing, calling 911, naloxone administration)?

Did Participant Report a Recent Overdose (Self or Witnessed)? (required)

Document any overdose event reported during this encounter for surveillance purposes.

Was Naloxone Used Since Last Visit?

If returning participant, did they report using naloxone to reverse an overdose since their last encounter?

Health Services and Wound Care

Health Services Provided at This Encounter

Select all services delivered during this visit.

Wound / Abscess Location (if wound care provided)

Select primary wound site if wound care was delivered.

Wound / Abscess Severity

HIV Rapid Test Result

Record result only if test was administered. Do not record result if participant declines disclosure.

Hepatitis C Rapid Test Result

Record result only if test was administered.

Referrals Made

Referrals Offered to Participant

Select all referrals offered, regardless of whether participant accepted.

Referrals Accepted by Participant

Select all referrals the participant agreed to pursue. Leave blank if none accepted.

Warm Handoff Completed?

Was a direct introduction or phone call made to connect the participant to a referred service during this encounter?

Participant Interest in MOUD / Treatment

Capturing readiness to change supports program evaluation and follow-up outreach.

Participant Demographics (First Visit Only)

Privacy Notice

The following questions are voluntary and anonymous. Demographic data is collected in aggregate for state reporting only. No individual-level data is shared with law enforcement or other agencies. Participant may decline any or all questions.

Age Range

Select participant's approximate age range. Do NOT record date of birth.

Gender Identity

Race / Ethnicity

Select all that apply.

Primary Substance Used (Self-Reported)

Substance most frequently used; used for program planning and state reporting.

Current Housing Status

Staff Notes and Encounter Summary

Encounter Notes

Record any relevant observations, safety concerns, follow-up actions, or service gaps. Use anonymous language only (e.g., 'participant' not name).

Safety Concern Flagged for Follow-Up? (required)

Flag if this encounter requires supervisor review, mandatory reporting consideration, or follow-up outreach.

Follow-Up Scheduled or Planned?

Planned Follow-Up Date

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