HomeMy WebLinkAboutHepatitis C
Idaho
Departm ent of
Correction
Standard
Ope rating
Proce dure
Div ision of
Education
T reatme nt
and Re e ntry
Ope rational
Serv ice s
Control Numbe r:
401.06.03.077
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3.0
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Adopte d:
10-30-2002
Re v ie we d:
07-26-2013
T itle:
Hepatitis C
This document was approved by Shane Evans, chief of the Division of Education, Treatment, and Reentry, on 09/09/2013 (signature on file).
Open to the public: Yes No
If no, is there a redacted version available: Yes No
BOARD OF CORRECTION IDAPA RULE NUM BER 401
Medical Care
POLICY CONT ROL NUMBE R 401
Clinical Servic es and Treatm ent
DEFINIT IONS
Standardiz ed Terms and Definitions List
Exposure Control Plan: A plan that describes ac tions that s taff may take to elim inate or
m inim ize exposure to pathogens .
Health Authority: The Idaho Department of Correction (IDOC) em ployee who is primarily
res pons ible for overseeing or managing the IDOC’s m edical services. (The health authority
is com monly referred to as the health services director.)
Health Care Provider: Health care prac titioners are c linicians trained to diagnose and treat
patients.
Hepatitis C Virus (HCV): A blood borne, infec tious, viral disease that is caus ed by the
hepatitis C virus. The infection can cause liver inflammation that is often asym ptomatic, but
ensuing chronic hepatitis can res ult later in cirrhos is (scarring of the liver) and liver cancer.
Clinical Practice Guideline: A s ys tem atic ally developed, science-based guideline
(presented by a national profess ional organiz ation and accepted by experts in their
res pective m edical field) des igned to ass ist the practitioner and patient with dec is ions about
appropriate healthc are for specific c linical c ircumstances.
Contract M edical Provider: A private company or other entity that is under contrac t with
the Idaho Departm ent of Correction (IDOC) to provide comprehens ive medical, dental,
and/or m ental health services to the IDOC’s inc arcerated offender population.
M edical Director: A phys ic ian either em ployed by the Idaho Departm ent of Correc tion
(IDOC) or c ontracted through privatiz ed services (i.e., the physic ian in charge if m edical
services are privatiz ed).
Mid-level Provider: A physic ian ass is tant or nurse prac titioner.
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Q ualified Health Professional: A physician, phys ician assis tant, nurse practitioner, nurse,
dentist, mental health profess ional, or other health professional who — by virtue of his
educ ation, training, credentials, and experience — is perm itted by law (within the scope of
his pr ofessional practice) to educ ate, train, evaluate, provide services, and care for patients.
Regional Health Manager: The individual (a) as s igned as the primary m anager, and (b)
adm inistratively res ponsible for the delivery of medical services, if health s ervices are
privatiz ed.
Regional Medical Director: An employee of the contract m edical provider, the phys ician
ass igned with the res pons ibility of overseeing all clinical as pects of health care in
acc ordance with the term s of the contractual agreem ent between the contract m edical
provider and the departm ent.
PURPOSE
The purpose of this s tandard operating proc edure (SOP) is to provide evidenc e-based
guidance to contract medical providers to establish a program to identify, couns el, evaluate
and treat patients with hepatitis C, with the goal of preventing disease transmiss ion and
pr ogression and fostering im provement in func tion.
The guidelines for screening, testing, couns eling, evaluation and treatm ent in this SOP are
based on the most rec ent inform ation from the National Ins titute of Health (NIH), Centers for
Disease Control and Prevention (CDC) and other nationally rec ognized sc ience-based
literature.
The Federal Bureau of Prisons (BOP) c linical prac tice guideline is based upon
rec omm endations of NIH and CDC, as well as current scientific res earch from a wide variety
of sources , and is the standard adopted by the Departm ent for the identific ation, evaluation
and treatm ent of Hepatitis C. As the BOP c linical prac tice guideline is updated to reflect new
scientific evidenc e, this SOP will be revised acc ordingly.
In addition to requiring the contract m edical provider to develop protoc ols c ons istent with the
BOP c linical prac tice guideline, this SOP provides specific procedures for screening, tes ting,
notification, and couns eling offenders with Hepatitis C.
SCOPE
The scope of this SOP inc ludes offenders , contract m edical s taff, and Idaho Departm ent of
Correction (IDOC) s taff members involved in the treatm ent, ass es s m ent, or couns eling of
affec ted offenders .
RESPONSIBILITY
The departm ent health authority is res pons ible to oversee the im plementation and continued
prac tice of the provisions contained in this SOP.
The contract m edical provider is res pons ible to im plement and practic e the provis ions of this
SOP.
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TABLE OF CONT ENTS
1. Clinical Practice Guidelines and Protocols ................................................................... 3
2. Sc reening .................................................................................................................... 3
3. Tes ting ......................................................................................................................... 4
4. Notification and Couns eling ......................................................................................... 4
5. Evaluation and Treatment ............................................................................................ 5
6. Compliance .................................................................................................................. 6
References ........................................................................................................................... 6
GENERAL REQUIREM ENTS
1. Clinical Practice Guide line s and Protocols
The contract m edical provider shall establish and utiliz e clinical protoc ols for the evaluation
and treatment of hepatitis C that are consis tent with the Federal Bureau of Prisons Clinical
Practice Guidelines for the Evaluation and Treatm ent of hepatitis C and c irrhosis.
The protoc ols m ust be reviewed and approved by the departm ent’s health services director
prior to implem entation. The pr otoc ols shall be submitted to the health services director
within 30 days of publication of this SOP.
The contractor’s regional m edical director and the departm ent’s health s ervices director shall
review and approve the protoc ol annually to ens ure that the protoc ol is cons is tent with the
m ost recent version of the BOP c linical prac tice guideline. Doc um entation of the annual
review shall be kept on file in each fac ility’s m edical unit.
Any deviation from the established protoc ols must be approved by a physic ian, docum ented
in the offender’s m edical file, and supported by clinical evidenc e.
2. Scree ning
O ffenders shall be provided educ ational inform ation on the trans mission, natural his tory, and
m edical m anagem ent of HC V infection. The contract m edical provider’s qualified staff will
perform this func tion on intake at the rec eiving and diagnostic units (RDU).
Identifying persons with chronic HC V infection requires screening as ym ptomatic persons ,
s ince the m ajority of pers ons with HCV are not ill. The Centers for Disease Control and
Prevention (CDC) rec om m ends screening persons at increased risk of infec tion, since
identifying persons with HC V infec tion provides an opportunity for patient couns eling,
m edical evaluation and treatm ent. Candidates for ris k-based testing inc lude offenders who
have ever:
injected illegal drugs;
rec eived a blood trans fusion or organ transplant prior to July 1992;
rec eived a clotting factor transfus ion prior to 1987;
been on long-term hem odialys is ;
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rec eived tattoos or body piercings while incarcerated.
Appendix A, Offender Hepatitis Fac t Sheet, shall be dis tributed to all offenders at intake by
the contract m edical provider’s qualified s taff at intake in the RDU. Bas ed upon the
information provided, the offender may subm it a health services request to rec eive a test to
determ ine the presence of hepatitis infec tion.
Appendix A, Offender Hepatitis Fac t Sheet, shall be made available to all offenders in the
m edical units . At any time during inc arceration, offenders m ay subm it a health services
request to rec eive tes ting.
3. T e sting
In addition to the risk-based testing required in section 2, “Sc reening,” the contract m edical
provider shall routinely test offenders for HC V infec tion based on clinical indications,
inc luding:
signs and s ymptoms of hepatitis ;
elevated ALT levels of unknown etiology;
concurrent infections with HIV or HB V;
presence of medical conditions s trongly ass oc iated with HCV infec tion s uch as
cryoglobulinem ia, m em branoproliferative glom erulonephritis, and porphyria cutanea
tarda.
Non-infec ted offenders on chronic hem odialysis should be s c reened for HCV infection by
ass aying ALT levels m onthly; and anti-HC V by imm unoassay s emiannually.
Following an exposure to blood or body fluids, IDOC staff shall follow the fac ility exposure
control plan. offenders shall be tes ted appropriately following an evaluation.by the fac ility
health authority.
Tests for HC V infection s hould be performed by appropriately accredited laboratories, and
ordered and interpreted by appropriately qualified health profes s ionals in accordance with
the established protoc ols , cons istent with the BOP clinical prac tice guideline. The preferred
screening test for HC V infection is an immunoassay that m eas ures antibodies to HCV
antigens .
4. Notification and Counseling
Al l HC V-Ab pos itive patients m us t be notified and couns eled conc erning hepatitis C
infec tion. During the course of evaluation via the c hronic disease program, further
couns eling may be indic ated and tailored to spec ific c o-m orbid conditions ass oc iated with
the offender’s m edical s tatus . This counseling may inc lude advice concerning m anagement
of depress ion, alcoholis m, weight reduction if obes e, control of diabetes , and control of other
m edical problem s.
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Functional Roles and
Re sponsibilities
Step
T asks
CIS steps are in bold
Qualified he alth
professional
1 Learns that an offender has tested pos itive for HCV-Ab.
2 W ithin fourteen (14) days, schedules an appointm ent with
the offender.
3 Couns el the offender regarding the pos itive diagnos is.
4 Give the offender copies of appendix C, Information For
Offenders Infec ted W ith Hepatitis C.
Offe nde r 5 Read appendix C. (If the offender cannot read or cannot
unders tand the m aterial, the m edical profess ional shall
read the material to the offender.)
6 After reading the material, signs the form and returns it to
the m edical profess ional.
Qualified he alth
professional
7 Provide the offender a copy of the signed form , appendix C,
and ensures that the form is filed in the offender’s m edical
file.
8 Doc uments the couns eling in the offender’s m edical rec ord.
9 Enrolls the offender in the chronic care clinic where
qualified health care profess ionals will complete follow-up
evaluations at intervals to be determ ined by a phys ic ian or
licensed mid-level provider and in acc ordance with the
protoc ol es tablished by the contract medical provider,
which must be cons istent with the BOP clinical prac tice
guideline.
10 As necess ary, provides further couns eling spec ific to the
co-m orbid conditions as soc iated with the offender’s medical
status.
5. Ev aluation and T reatme nt
Evaluation and treatm ent of hepatitis C shall be c onducted in accordance with protoc ols
established by the contract m edical provider, cons istent with the BOP clinical prac tice
guideline and approved by the departm ent’s health s ervices director prior to implem entation.
Appendix B, Consent for Hepatitis C Evaluation and Treatm ent, shall be completed prior to
initiating treatm ent with interferon and ribavirin; (Dual Therapy), or with interferon, ribavirin
and boceprevir or telaprevir (Triple Therapy). Triple Therapy is us ed for HCV genotype 1
only.
If the offender declines evaluation and/or therapy, a refus al of treatment form should be
completed, and signed by the m edical provider and the offender. The form should be faxed
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to the department’s health services direc tor and the original plac ed in the offender’s m edical
file.
6. Compliance
Compliance with this SO P and the established departm ent-approved protocols will be
m onitored via routine and cas e-spec ific audits and rec ord reviews conducted by the
departm ent’s health services director or des ignee.
REFERENCES
Appendix A, Offender Hepatitis Fac t Sheet
Appendix B, Consent For Hepatitis C Evaluation and Treatm ent
Appendix C, Information for Offenders Infected W ith Hepatitis C
Appendix D, Mental Health Review for Hepatitis C Patients on Interferon/Ribavirin Therapy.
Centers for Disease Control and Prevention, Prevention and Control of Infections with
Hepatitis Virus es in Correctional Settings , MMW R 2003; 52 (No. RR-1): 1-36
Federal Bureau of Prisons, Clinical Practice Guidelines for the Prev ention and Treatm ent of
Viral Hepatitis , October 2005.
National Com mission on Correctional Health Care, Standards for Health Servic es in Prisons ,
2003.
National Institutes of Health Cons ens us Statem ent on M anagem ent of Hepatitis C: 2002;
NIH Consensus and State-of-the-Science Statem ents , Volume 19, Number 3, June 10-12,
2002
– End of Doc um ent –
IDAHO DEPARTMENT OF CORRECTION
OFFENDER HEPATITIS FACT SHEET
Am I at risk of being infected with hepatitis B virus (H B V) or hepatitis C virus
(HCV)?
You may be at risk for HBV or HC V infection if you ha ve ever injected drugs or had sex
with an infected partner. HBV is more easi ly tra nsmitted through sex and from a mothe r
to her child compared to HCV. Persons receiving blo od transfusions pri or to 1992 may
be at risk for HC V infecti on. Talk to a health care pro vider about the risks of i nfection
tha t affe ct you persona lly.
How can I prevent getting HCV or H BV w hile I am in prison?
Do no t ha ve sex with othe r offe nders, sho ot drugs, or get a tattoo or body piercing.
Do no t sha re toothbrushe s, razors, nail clippi ng devices, or other personal items that
might ha ve blood on them with othe r offe nders.
Are these infections dangerous to my health?
Most persons infected with HBV or HCV do not develop serious health pro blems;
ho wever, a small but signi ficant num ber of patients develop serious li ver disease. Talk
to a health care pro vider about personal risks for develo ping li ver disease.
Why should I be tested for H BV or HC V infection?
You should be tested if you are at risk so doctors can monitor your i nfection and assess
your need for treatment no w or in the future. You should also be tested so that you can
better prevent othe rs from getting infected, i ncluding your infant i f you are pregnant.
How do I get tested for HBV or H CV?
A simple blood test can determi ne if you are infected.
How can I prevent giving HB V or H CV to others if I am already infected?
First, re member that you can spread the se i nfecti ons even if you feel fine.
Do no t shoot drugs or have sex with other offenders.
Do no t share persona l items tha t might ha ve your blood on them, such as toothb rushe s,
dental appliances, nai l-cli pping equipment or razors.
Cover your cuts and skin sores to keep your blo od from contacting othe r persons.
If you are being released, talk to a health care provider about specific ways you can
re duce the risk of spreading HBV or HCV to othe rs.
After reading this i nforma ti on, if you ha ve additiona l que sti ons or would like to reque st a
test for hepatitis C, please submit a health services reque st form to the medical staff.
401.06.02.077, A ppendix A
Revised 4/5/06
IDAHO DEPARTM ENT OF CO RRECTION
Consent for Hepatitis C Evaluation and Treatm ent
Offender Name Num ber Fac ility
1. I understand that I have hepatitis C infec tion and that blood tes ts have sugges ted that there
is active injury to m y liver. I agree to proceed with further evaluation of m y liver with a li ver
biopsy, ultras ound (sound wave) test, and further blood tes ts. I unders tand that there are
certain ris ks ass oc iated with the liver biops y that inc lude possible allergic reac tion to the
loc al anesthetic us ed to num b m y s kin, pain at the area where the needle is ins erted,
possible severe bleeding, and possible injury to m y gallbladder or other internal organs.
However, I unders tand that the biopsy will be perform ed by personnel trained in this
procedure, that the biopsy will be perform ed only if I have normal blood clotting and no fluid
acc um ulation in m y abdom inal cavity (asc ites ), and that I will be observed for at least two (2)
hours after the biopsy and then be relieved of any work and not do any s trenuous activity for
the rest of that day and the next.
2. I understand that if I have s ignificant active dam age and scar tissue formation revealed by
m y liver biopsy, I would be a c andidate for receiving Interferon and Ribavirin treatment. I
unders tand that the biopsy m ight show only a s mall amount of dam age, in which case I
would not be offered Interferon and Ribavirin therapy.
3. I unders tand that this is a complicated and complex treatm ent that m ust be m onitored
c los ely, and due to the significant toxicities of the interferon and ribavirin, treatm ent should
not begin unless it can be completed prior to m y release from cus tody, unless continuity of
care can be ass ured upon trans ition to the c om munity. The time required for evaluation,
treatm ent, and follow-up testing will be determined by the treating phys ician and will depend
upon multiple clinical variables. I will be hous ed in a s ingle IDOC fac ility for the duration of
evaluation, treatm ent, and follow-up testing.
4. I unders tand that there are m any s ide effec ts of rec eiving Interferon and Ribavirin. Inter feron
will be injected under m y s kin either three (3) times a week or weekly and can cause fatigue,
ac hing, headac he, loss of appetite, weight los s, difficulty sleeping, anxiety, irritability, and
severe depress ion which m ay cause me to become suicidal. Interferon can also lower m y
white blood cells and platelets and also cause thyroid problems. Ribavirin pills will be taken
twice a day and this medication can cause breakdown of m y red blood c ells with a res ulting
anemia. It can also cause a skin ras h, itching, s hortness of breath, cough, sore throat, nasal
congestion, stom ach pain and loss of appetite. These side effects of Interferon and Ribavirin
can be severe and can c ause death. I understand that I will need to make frequent vis its to
the prison m edical unit to have blood tests and that the Interferon and Ribavirin doses m ay
have to be adjus ted or discontinued.
5. I understand that no prom ises or guarantees have been m ade to m e that I will rec eive the
Interferon and Ribavirin after the liver biopsy and that if I do rec eive these m edications, I
unders tand that this therapy may not eliminate the hepatitis C virus or prevent cirrhosis of
the liver or prevent the development of liver cancer.
6. I unders tand that if I have a history of drug and alcohol abus e, I m ay be r eferred to a
subs tance abuse progr am. I unders tand that I m ay be random ly tested during therapy for
401.06.02.077, Appendix B
Revised 4/5/06
illegal drugs and alcohol. I unders tand that if I c ontinue to use alcohol or illic it drugs during
treatm ent for hepatitis C, or otherwise demonstrate nonc om pliance with the presc ribed
treatm ent regimen, therapy m ay be discontinued.
7. I understand that Ribavirin can cause birth defec ts. If I am a woman, I must not become
pr egnant while on Ribavirin and for s ix (6) m onths after I stop taking it. If I am a man, I must
not impregnate any woman for the tim e I am on Ribavirin and for s ix (6) months after I stop
taking it.
8. I have discuss ed with my phys ic ian the following risks or issues in addition to those
m entioned above concerning m y medical condition and the evaluation and treatm ent of m y
hepatitis C:
9. I have discuss ed with m y doc tor the ris ks/benefits of having a liver biopsy and rec eiving
Interferon and Ribavirin. Al l m y ques tions have been ans wered in the terms and language
that I understand.
I agree to have further evaluation of m y hepatitis C with a liver biops y, ultras ound
test and m ore laboratory s tudies. If indicated, I agree to rec eive Interferon and
Ribavirin for treatment of m y hepatitis C.
I dec line further evaluation of m y hepatitis C and do not wish to have a liver
biopsy and unders tand that I will not rec eive Interferon and Ribavirin treatm ent.
Offender's Signature Date
Phys ician’s Signature Date
401.06.02.077, Appendix B Original To Offender's Chart
Revised 4/5/06 Fax One Copy To Central Office
IDAHO DEPART MENT OF CORRECTION
INFORMAT IO N FOR OFFENDERS INFECTED WIT H HEPAT IT IS C
A rec ent blood test showed that you have an infection with the hepatitis C virus (HCV). This is a
virus, which could serious ly hurt your liver. You may have had HC V for a long tim e. You may have
gotten the virus from being given contaminated blood or blood products before 1992 when the
virus could not be detected. You m ay have gotten the virus from contaminated needles abus ing
intravenous drugs . Even if you abus ed drugs only a few tim es many years ago, you may have
gotten HC V bac k then and never knew it. Frequent high-risk sexual contact is also thought to
spread the virus. Tattoos and body piercing could also have been the source of the infection.
Fortunately, the majority of HC V infected people do not develop serious liver damage and the virus
is not eas ily trans mitted to others , even with c lose contac t. However, it is im portant that we find out
whether you are one of the people who have serious liver dam age from HCV and find out if we can
s low dam age being done to your liver. Al though there is FDA-approved therapy to try to reduce or
eliminate the virus, the currently approved Interferon and Ribavirin treatm ent is not always
succ es s ful and the treatment (shots and pills) is hard to tolerate with serious s ide-effects. A liver
biopsy is us ually required to determine if this therapy is indicated. For those who develop liver
damage from HC V (cirrhos is of the liver and liver failure), it us ually takes many years to develop
s ignificant liver dam age. Al though that sounds like a lot of time, if you were infec ted m any years
ago and did not know it, you may have more dam age than you think.
If you are interes ted in being evaluated for your HC V infection, you will be as ked to have more
blood tests. However, due to the significant toxicities of the interferon and ribavirin, treatm ent shall
not begin unless it can be completed prior to your release from cus tody, unless continuity of care
can be assured upon trans ition to the com m unity. The time required for evaluation, treatm ent, and
follow-up testing will be determined by the treating physic ian and will depend upon m ultiple clinical
variables. You m us t als o not have any risks that would m ake Interferon and Ribavirin therapy
dangerous for you. Then, if your blood tests show pers istent active liver damage, you will be
advised to have a liver biops y.
If your biopsy shows that you would benefit from therapy with Interfer on and Ribavirin, then this
therapy will be offered to you in hopes of clearing the virus and s topping further liver dam age.
Following are s ome “Frequently Asked Questions” and ans wers taken from the Ce nters for
Disease Control (CDC):
Q. What is he patitis C?
Hepatitis C is a virus (HCV) that can cause liver disease. The virus is found in the blood and liver of
infec ted people and lives in the liver for many years. Most people who have HC V do not get
serious liver disease. About fifteen percent (15%) to twenty percent (20%) of infected people
develop c irrhos is and liver failure after several decades of infection.
Q. How could a pe rson hav e gotten he patitis C?
HC V is spread primarily by direct contact with human blood. For example, you may have gotten
infec ted with HCV if:
You had a blood transfus ion prior to 1992;
401.06.03.077, Appendix C
Revise d 4/5/06
You once injected s treet drugs, and the needle and/or other drug paraphernalia us ed to
prepare or inject drugs had someone else’s blood that contained HCV on them ;
If you have ever had sex with a person infec ted with HCV; or
You lived with som eone who was infected with HCV and shared items s uch as raz ors or
toothbrus hes that m ight have had his blood on them.
Q. How can pe rsons infe cted with HCV pre v ent spre ading HCV to othe rs?
Do not share personal items that m ight have your blood on them such as toothbrus hes ,
dental appliances, nail c lippers, or raz ors;
Cover your cuts and skin sores to keep from spreading HCV;
Do not have unprotec ted sex; and
Do not share needles, tattoo or body piercing equipment.
Q. How can pe ople prote ct the ms e lv es from ge tting he patitis C and other disease s
spread by contact with human blood and body fluids?
Do not inject drugs;
If you inject drugs, stop and get into a subs tance abuse program . Never reuse or share
s yringes, water (us ed for injec tions) or drug paraphernalia;
Do not get a tattoo or any body piercing; and
Remem ber HC V can be spread by sexual activity, but at a very low rate.
Q. What can persons with HCV infe ction do to protect the ir liv er?
Stop using all alcohol;
Stop using all s treet drugs;
Do not take over-the-c ounter, herbal, or other m edications without your doc tor’s
knowledge;
Avoid being overweight; and
Consider other m eas ures your doc tor may recom m end (iron reduction and Vi tamin E).
Q. What othe r informa tion should you be aware of?
HC V is not spread by sneezing, coughing, food or water, sharing eating utens ils or
drinking glass es, or by cas ual contac t;
A person can be re-infected, as prior infec tion does not give protection against a
different strain; and
Your doctor will m ake m edical decis ions based on your m edical status and evaluation.
Offender’s Name (printed): IDOC Num ber:
Offender's Signature: Date
Phys ician’s Signature: Date
401.06.03.077, Appendix C Original to Offender’s Medical File
Revise d 4/5/06 Copy to Offender
IDAHO DEPART M ENT OF CORRECTIO N
MENTAL HEALTH REVIEW FOR HEPAT IT IS C PAT IENT S ON
INT ERFERON/RIBAVIRIN T HERAPY
Offender Name Num ber Fac ility
Severe depress ion and other ps ychiatric disorders can oc cur as a s ide effec t of Inter feron
therapy. Some hepatitis C patients should be started on antidepres s ant m edications before
Inter feron and Ribavirin therapy is begun. The following ques tions should be as ked at each
m edical follow-up appointment. If there are any affirm ative res ponses, a referral to correc tion
outpatient ps ychiatric services should be m ade.
Date Interferon Started
Week of Inte rferon/ Ribav irin T herapy: (Circ le "Y" for Yes or “N" for No, for each visit)
1 2 4 8 12 16 20 24 Que stions:
Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Have you had any serious suic idal
thoughts, developed a plan for suicide or
had a suic ide attempt within the pas t four
(4) weeks?
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Have you experienced hearing voices or
seeing things that thos e around you have
not, m ore than once within the past four (4)
weeks?
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Have you experienced a significant change
in your mood that has las ted at leas t two (2)
weeks?
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
In the pas t two (2) weeks, have you
experienced crying epis odes or feelings of
uncontrollable rage that were not in
res ponse to bad news or another serious
event?
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
In the past two (2) weeks, have you felt that
you possess spec ial powers, such as the
ability to read people’s m inds, com m unicate
with spirits or control others?
If offe nder answers “Ye s” at any time to any que stion, hold Inte rfe ron and Ribav irin Rx
and make re fe rral to the M e dical Director.
Mental Health Profess ional Signature Date of Referral:
401.06.03.077, Appendix D Original to Offender’s Chart
Revised 4/5/06