csat gpra k¬v‡q›u djvdj †¯^”qvaxb kg©m~wp¸‡jvi rb¨ c`‡¶cmg ... · dig aby‡gvw`z...

SAIS_GPRA_Client_Outcome_Instrument v4.6

dig Aby‡gvw`Z

OMB bs: 0930-0208

†gqv‡`vËx‡Y©i ZvwiL 01/31/2016

CSAT GPRA K¬v‡q›U djvdj

†¯^”Qvaxb Kg©m~wP¸‡jvi Rb¨ c`‡¶cmg~n

(cwigvwR©Z 06/01/2012)

hw` me¸‡jv AvB‡Ug †Kv‡bv K¬v‡q›U/AskMªnYKvix‡K wR‡Ám Kiv nq, Zvn‡j GB Z_¨ msMª‡ni Rb¨ RbM‡Yi

cªwZ‡e`‡bi ¸i“fvi wn‡m‡e cªwZwU Rev‡ei Rb¨ M‡o 30 wgwbU K‡i mgq jvM‡e e‡j Abygvb Kiv n‡q‡Q, Gi g‡a¨ Aš—

fz©³ i‡q‡Q wb‡`©kbv ch©v‡jvPbv, we`¨gvb Z_¨fvÛvi AbymÜvb, cª‡qvRbxq Z_¨ÑDcvË msMªn I i¶Yv‡e¶Y, Ges

msM„nxZ Z_¨ m¤ú~Y© Kiv I ch©v‡jvPbvi Rb¨ e¨wqZ mgq; hw` †cªvfvBWviiv Zv‡ì Pjgvb K¬v‡q›U/AskMªnYKvix

Bb‡UK ev d‡jvAv‡ci Ask wn‡m‡e GB Z‡_ï A‡bKLvwb BwZg‡a¨B msMªn K‡i _v‡K Zvn‡j Zvi Dci wfwË K‡i, mgq

Kg jvM‡e| GB AvbygvwbK ¸i“fvi m¤ú‡K© A_ev Z_¨ msMªn m¤úwK©Z Ab¨ †h †Kv‡bv wel‡q GB wVKvbvq gZvgZ

cvVvb: SAMHSA Reports Clearance Officer, Room 7-1044, 1 Choke Cherry Road, Rockville, MD 20857. eZ©gv‡b êa

†Kv‡bv OMB K‡›U«vj b¤¦i cª`k©b bv Ki‡j †Kv‡bv G‡RwÝ cwiPvjbv ev c„ô‡cvlKZv bvI Ki‡Z cv‡i, Ges †Kv‡bv e¨w³

Z_¨ msMª‡ni Aby‡iv‡a mvov †`qvi Rb¨ eva¨ bq| GB cª‡R‡±i Rb¨ K‡›U«vj b¤¦i n‡”Q 0930-0208.

SAIS_GPRA_Client_Outcome_Instrument 1 v4.6

A. †iKW© eë¯’vcbv

K¬v‡q›U ID |____|____|____|____|____|____|____|____|____|____|____|____|____|____|____|

K¬v‡q‡›Ui aib:

wPwKrmvaxb K¬v‡q›U

wbivgqiZ K¬v‡q›U

K›U«v±/Mª¨v›U ID |____|____|____|____|____|____|____|____|____|____|

mv¶vrKv‡ii aib [ïaygvÎ GKwU ai‡b †Mvj`vM w`b|]

Bb‡UK [mv¶vrKv‡ii Zvwi‡L P‡j hvb|]

6 gv‡mi d‡jvAvc → → → Avcwb wK †Kv‡bv d‡jvAvc mv¶vrKvi cwiPvjbv K‡i‡Qb? nu¨v bv

[hw` bv nq, mivmwi †mKkb IÑ†Z P‡j hvb|]

3 gv‡mi d‡jvAvc [ïaygvÎ wK‡kviÑwK‡kvix‡ì †cvU©‡dvwjI] →

Avcwb wK †Kv‡bv d‡jvAvc mv¶vrKvi cwiPvjbv K‡i‡Qb? nu¨v bv

[hw` bv nq, mivmwi †mKkb IÑ†Z P‡j hvb|]

wWmPvR© → → → Avcwb wK †Kv‡bv wWmPvR© mv¶vrKvi cwiPvjbv K‡i‡Qb? _______________ nu¨v bv

[hw` bv nq, mivmwi †mKkb JÑ†Z P‡j hvb|]

mv¶vrKv‡ii ZvwiL |____|____| / |____|____| / |____|____|____|____|

gvm w`b eQi

[d‡jvAvc Ges wWmPvR© mv¶vrKvi: †mKkb BÑ†Z P‡j hvb|]

1. Avcbvi K¬v‡q›U‡K wK hyMcrfv‡e gvbwmK ¯^v¯’¨ Ges gv`K`ªe¨ eënviRwbZ e¨vwa‡Z †fvMvi Rb¨ Avcbvi

Kg©m~wP‡Z Aš—f©z³ Kiv n‡q‡Q?

nu¨v

bv [1a.ev` w`‡q GwM‡q hvb]

1a. [hw` nu¨v nq] K¬v‡q›U wK gvbwmK ¯^v¯’¨ Ges gv`K`ªe¨ eënviRwbZ e¨vwa‡Z GKmv‡_ †fvMvi

welqwU aiv c‡o‡Q?

nu¨v

bv

[SBIRT Pj‡Q| Ab¨ mevB †mKkb A ÒcwiKwíZ cwi‡levmg~nÓ†Z P‡j hvb|]


GB †mKkbwU ïaygvÎ SBIRT gÄzwimg~‡ni Rb¨ [AvB‡Ug 2, 2a, I 3 - ïaygvÎ Bb‡UK/†emjvBbÑG D‡jL Kiv

n‡q‡Q]|

2. Avcbvi SBIRT-Gi Rb¨ K¬v‡q›U †Kgb w¯Œb K‡i‡Qb?

†b‡MwUf

c‡RwUf

2a. Zvi w¯Œwbs †¯‹vi KZ wQj? AUDIT = |____|____|

CAGE = |____|____|

DAST = |____|____|

DAST-10 = |____|____|

NIAAA MvBW = |____|____|

ASSIST/A¨vj‡Kvnj mve‡¯‹vi = ________________ |____|____|

Ab¨vb¨ (D‡jL Ki“b) = |____|____|

______________________________________

______________________________________

______________________________________

3. wZwb wK SBIRT Kg©m~wP‡Z Zvi AskMªnY Ae¨vnZ ivL‡Z B”QzK wQ‡jb?

nu¨v

bv


A. †iKW© eë¯’vcbv Ñ cwiKwíZ cwi‡levmg~n [ïaygvÎ Bb‡UK/†emjvB‡b K¬v‡q›U m¤ú‡K© Kg©m~wPi

Kg©x‡ì Øviv wi‡cvU©K…Z]

K¬v‡q‡›Ui wPwKrmv/Av‡ivM¨jv‡fi mg‡q Avcwb

K¬v‡q›U‡K †h me cwi‡lev¸‡jv †`qvi cwiKíbv Ki‡Qb

†m¸‡jv wPwýZ Ki“b| [cªwZwUi Rb¨ nu¨v n‡j Ônu¨vÕ †Z

A_ev bv n‡j ÔbvÕ †Z †Mvj`vM w`b|]

wPwKrmvi aib nu¨v bv

[Kgc‡¶ GKwU aib wbe©vPb Ki“b|]

1. †Km eë¯’vcbv nu¨v bv

2. wèvKvjxb wPwKrmv nu¨v bv

3. fwZ© nIqv †ivMx/nvmcvZvj (gv`Kvkw³

wbivgq e¨ZxZ) nu¨v bv

4. ewnwe©fvMxq †ivMx nu¨v bv

5. AvDUwiP nu¨v bv

6. wbweo ewnwe©fvMxq †ivMx nu¨v bv

7. †g_v‡Wvb nu¨v bv

8. AvevwmK/cybe©vmb nu¨v bv

9. gv`Kvkw³ wbivgq (ïaygvÎ GKwU wbe©vPb

Ki“b)

A. nvmcvZv‡j fwZ© nIqv †ivMx nu¨v bv

B. wd« ÷¨vwÛs AvevwmK nu¨v bv

C. ewnwe©fvMxq †ivMx‡ì gv`Kvkw³

wbivgq nu¨v bv

10. cieZ©x cwiPh©v nu¨v bv

11. wbivg‡q mnvqZv nu¨v bv

12. Ab¨vb¨ (D‡jL Ki“b) _______________ nu¨v bv

[Kgc‡¶ GKwU cwi‡lev wbe©vPb Ki“b|]

wPwKrmv †mev nu¨v bv

[SBIRT gÄzwi: 1 †_‡K 4 Gi g‡a¨ GKwU

wPwKrmv †mevq Avcbv‡K Aek¨B Ônu¨vÕ †Z

†Mvj`vM w`‡Z n‡e|]

1. w¯Œwbs nu¨v bv

2. msw¶ß n¯—‡¶c nu¨v bv

3. msw¶ß wPwKrmv nu¨v bv

4. wPwKrmvi Rb¨ †idvi Kiv nu¨v bv

5. g~j¨vqb nu¨v bv

6. wPwKrmv/wbivg‡qi cwiKíbv nu¨v bv

7. e¨w³MZ civgk© †mev nu¨v bv

8. `jMZ civgk© †mev nu¨v bv

9. cvwievwiK/êevwnK civgk© nu¨v bv

10. hyMcr wPwKrmv/

wbivgq †mev nu¨v bv

11. IlyawfwËK n¯—‡¶c nu¨v bv

12. HIV/GBWm m¤úwK©Z civgk© nu¨v bv

13. Ab¨vb¨ wPwKrmv †mev

(D‡jL Ki“b) ______________________ nu¨v bv

†Km eë¯’vcbv cwi‡lev nu¨v bv

1. cvwievwiK cwi‡lev (we‡q msµvš— wk¶v,

wcZ…Z¡/gvZ…Z¡, wkï Dbœqb cwi‡lev

mn) nu¨v bv

2. wkï cwiPh©v nu¨v bv

3. Kg©ms¯’vb msµvš— †mev

A. cªvKÑKg©ms¯’vb nu¨v bv

B. Kg©ms¯’vb msµvš— †KvwPs nu¨v bv

4. e¨w³MZ cwi‡levi mgš^q nu¨v bv

5. cwienb nu¨v bv

6. HIV/GBWm welqK cwi‡lev nu¨v bv

7. mnvqZvg~jK µvwš—Kvjxb gv`KÑgy³

Avevmb †mev nu¨v bv

8. Ab¨vb¨ †Km eë¯’vcbv cwi‡lev

(D‡jL Ki“b) _____________________ nu¨v bv

wPwKrmv †mev nu¨v bv

1. wPwKrmv cwiPh©v nu¨v bv

2. A¨vj‡Kvnj/gv`K cix¶v nu¨v bv

3. HIV/GBWm wPwKrmv mnvqZv I cix¶v nu¨v bv


(D‡jL Ki“b) _____________________ nu¨v bv

cwiPh©v cieZ©x †mev nu¨v bv

1. Ae¨vnZ cwiPh©v nu¨v bv

2. cybivq wjß nIqv cªwZ‡iva nu¨v bv

3. wbivg‡qi †KvwPs nu¨v bv

4. AvZ¥-mvnvh¨ I mnvqZv `j nu¨v bv

5. Ava¨vwZ¥K mnvqZv nu¨v bv

6. Ab¨vb¨ cwiPh©v cieZ©x †mev

(D‡jL Ki“b) _____________________ nu¨v bv

wk¶v cwi‡lev nu¨v bv

1. gv`‡Ki Aceënvi m¤úwK©Z wk¶v nu¨v bv

2. HIV/GBWm m¤úwK©Z wk¶v nu¨v bv

3. Ab¨vb¨ wk¶v cwi‡lev

(D‡jL Ki“b) _____________________ nu¨v bv

m½xiÑØvivÑm½xi wbivgq mnvqZv cwi‡lev nu¨v bv

1. m½x‡ì †KvwPs ev civgk© nu¨v bv

2. evm¯’vb mnvqZv nu¨v bv

3. A¨vj‡KvnjÑ I gv`KÑgy³ mvgvwRK

Kvh©µg nu¨v bv

4. Z_¨ I mycvwik nu¨v bv

5. m½xiÑØvivÑm½xi Ab¨vb¨ wbivgq

mnvqZv †mev

(D‡jL Ki“b) _____________________ nu¨v bv


A. †iKW© e¨e¯’vcbv Ñ RbmsL¨vZvwË¡K [ïaygvÎ Bb‡UK/†emjvB‡b wRÁvmv Kivi Rb¨]

1. Avcwb †Kvb wj‡½i?

cyi“l

gwnjv

U«vÝ‡RÛvi

Ab¨vb¨ (D‡jL Ki“b) _______________________________

DËi w`‡Z Abxnv

2. Avcwb wK wn¯úvwbK ev j¨vwU‡bv?

nu¨v

bv

DËi w`‡Z Abxnv

[hw` nu¨v nq] Avcwb wb‡R‡K †Kvb RvwZMZ `‡ji Aš—fz³ e‡j we‡ePbv K‡ib? AbyMªn K‡i wb‡Pi

cªwZwUi Rb¨ nu¨v ev bv DËi w`b| Avcwb GKwUi †ewk DË‡i nu¨v ej‡Z cv‡ib|

nu¨v bv DËi w`‡Z Abxnv

ga¨ Av‡gwiKvb nu¨v bv DËi w`‡Z Abxnv

wKDevb nu¨v bv DËi w`‡Z Abxnv

WwgwbKvb nu¨v bv DËi w`‡Z Abxnv

†gw·Kvb nu¨v bv DËi w`‡Z Abxnv

cy‡q‡Z©vwiKvb nu¨v bv DËi w`‡Z Abxnv

`w¶Y Av‡gwiKvb nu¨v bv DËi w`‡Z Abxnv

Ab¨vb¨ nu¨v bv DËi w`‡Z Abxnv [hw` nu¨v nq, wb‡P mywbw`©ófv‡e D‡jL Ki“b|]

(D‡jL Ki“b) _________________________________ _________________________

3. Avcwb †Kvb RvwZi? AbyMªn K‡i wb‡Pi cªwZwUi Rb¨ nu¨v ev bv DËi w`b| Avcwb GKwUi †ewk DË‡i

nu¨v ej‡Z cv‡ib|

nu¨v bv DËi w`‡Z Abxnv

K…òv½ ev Avwd«Kvb Av‡gwiKvb nu¨v bv DËi w`‡Z Abxnv

Gkxq nu¨v bv DËi w`‡Z Abxnv

nvIqvB ev Ab¨ cªkvš— gnvmvMixq Øx‡ci Awaevmx nu¨v ____________________________________ bv DËi w`‡Z Abxnv

Avjv¯‹vi Avw`evmx nu¨v bv DËi w`‡Z Abxnv

†k¦Zv½ nu¨v bv DËi w`‡Z Abxnv

Av‡gwiKvb BwÛqvb nu¨v bv DËi w`‡Z Abxnv

4. Avcbvi Rb¥w`b K‡e?*

|____|____| / |____|____| / [*wm‡÷g ïaygvÎ gvm I eQi msi¶Y Ki‡e|

gvm w`b †MvcbxqZv i¶vi Rb¨ w`‡bi Z_¨ msi¶Y Kiv n‡e bv|]

|____|____|____|____|

eQi

DËi w`‡Z Abxnv


mvgwiK cwievi I wb‡qvwRZKiY

5. Avcwb wK KL‡bv mk¯¿ evwnbx, wiRvf©, ev b¨vkbvj MvW© evwnbx‡Z KvR K‡i‡Qb? [hw` K‡i _v‡Kb]

mk¯¿ evwnbx, wiRvf©, ev b¨vkbvj MvW© evwnbxi †Kvb As‡k KvR K‡i‡Qb?

bv

nu¨v, mk¯¿ evwnbx‡Z

nu¨v, wiRvf© evwnbx‡Z

nu¨v, b¨vkbvj MvW© evwnbx‡Z

DËi w`‡Z Abxnv

Rvwb bv

[hw` bv, DËi w`‡Z Abxnv, ev Rvwb bv nq, Zvn‡j mivmwi cªkœ A6 G P‡j hvb|]

5a. Avcwb wK eZ©gv‡b mk¯¿ evwnbx, wiRvf©, ev b¨vkbvj MvW© evwnbx‡Z mwµqfv‡e `vwqZ¡ cvjb

K‡i‡Qb? [hw` K‡i _v‡Kb] †Kvb †¶‡Î, mk¯¿ evwnbx, wiRvf©, bvwK b¨vkbvj MvW© evwnbx?

bv, mk¯¿ evwnbx, wiRvf© ev b¨vkbvj MvW© evwnbx †_‡K wew”Qbœ ev Aemicªvß

nu¨v, mk¯¿ evwnbx‡Z

nu¨v, wiRvf© evwnbx‡Z

nu¨v, b¨vkbvj MvW© evwnbx‡Z

DËi w`‡Z Abxnv

Rvwb bv

5b. Avcbv‡K wK KL‡bv hy×‡¶‡Î wb‡qvwRZ Kiv n‡qwQj? [cª‡hvR¨ me¸‡jv‡Z wUKwPý w`b|]

KL‡bvB wb‡qvwRZ Kiv nqwb

BivK ev AvdMvwb¯—vb (†hgb, OEF/OIF/OND)

cvim¨ DcmvMi (Acv‡ikb †WRvU© wkì/†WRvU© ÷g©)

wf‡qZbvg/`w¶Yc~e© Gwkqv

†Kvwiqv

wØZxq wek¦hy×

Dc‡i D‡jL Kiv nqwb Ggb GKwU hy×‡¶‡Î wb‡qvwRZ Kiv n‡qwQj (†hgb, emwbqv/†mvgvwjqv)

DËi w`‡Z Abxnv

Rvwb bv

[SBIRT MªvnK: †h me K¬v‡q›U †b‡MwUf wn‡m‡e w¯Œwbs n‡q‡Qb, Zv‡`i Rb¨ AvB‡Ug A6, A6a †_‡K A6d ch©š—

mivmwi ev` w`‡q GwM‡q hvb]


6. Avcbvi cwiev‡ii †KD ev Avcbvi Nwbô †KD wK mk¯¿ evwnbx, wiRvf© ev b¨vkbvj MvW© evwnbx‡Z

mwµqfv‡e Kg©iZ Av‡Qb, A_ev mk¯¿ evwnbx, wiRvf© ev b¨vkbvj MvW© evwnbx †_‡K wew”Qbœ ev

Aemicªvß n‡q‡Qb?

bv

nu¨v, †KejgvÎ GKRb

nu¨v, GKvwaK

DËi w`‡Z Abxnv

Rvwb bv

[hw` bv, DËi w`‡Z Abxnv, ev Rvwb bv nq, Zvn‡j mivmwi †mKkb B †Z P‡j hvb|]

[hw` nu¨v nq, 6 Rb ch©š— e¨w³i Rb¨ DËi w`b] Avcbvi mv‡_ †mB e¨w³i (mvwf©m †g¤¦vi) m¤úK© Kx? [Kjv‡gi

wk‡ivbv‡g m¤úK© wjLyb]

1 = gv 2 = evev

3 = fvB 4 = †evb

5 = ¯^vgx/¯¿x 6 = cvU©bvi

7 = mš—vb 8 = Ab¨vb¨ (D‡jL Ki“b) ___________________

mvwf©m †g¤¦vi wK wb‡Pi

†Kv‡bvwUi m¤§zLxb

n‡qwQ‡jb? [cª‡hvR¨

me¸‡jvi Rb¨ h_vh_ DË‡ii

Kjv‡g wUKwPý w`b]

_________

(m¤úK©)

1.

_________

(m¤úK©)

2.

_________

(m¤úK©)

3.

_________

(m¤úK©)

4.

_________

(m¤úK©)

5.

_________

(m¤úK©)

6.

6a. mk¯¿ Acv‡ik‡b

mnvqZv Kivi Rb¨

wb‡qvwRZ Kiv

n‡qwQj wK (†hgb,

Biv‡K ev

AvdMvwb¯—v‡b)?

nu¨v

bv

DËi w`‡Z

Abxnv

Rvwb bv

nu¨v

bv

DËi w`‡Z

Abxnv

Rvwb bv

nu¨v

bv

DËi w`‡Z

Abxnv

Rvwb bv

nu¨v

bv

DËi w`‡Z

Abxnv

Rvwb bv

nu¨v

bv

DËi w`‡Z

Abxnv

Rvwb bv

nu¨v

bv

DËi w`‡Z

Abxnv

Rvwb bv

6b. mk¯¿ Acv‡ik‡b

kvixwiKfv‡e AvnZ

n‡qwQ‡jb?

nu¨v

bv

DËi w`‡Z

Abxnv

Rvwb bv

nu¨v

bv

DËi w`‡Z

Abxnv

Rvwb bv

nu¨v

bv

DËi w`‡Z

Abxnv

Rvwb bv

nu¨v

bv

DËi w`‡Z

Abxnv

Rvwb bv

nu¨v

bv

DËi w`‡Z

Abxnv

Rvwb bv

nu¨v

bv

DËi w`‡Z

Abxnv

Rvwb bv

6c. hy‡×i Pv‡ci j¶Y¸‡jv

†`Lv w`‡qwQj/

wb‡qvwRZ nIqvi ci

gvwb‡q wb‡Z mgm¨v

n‡qwQj, hvi g‡a¨

i‡q‡Q PTSD,

welbœZv, ev

AvZ¥nZ¨vi wPš—v?

nu¨v

bv

DËi w`‡Z

Abxnv

Rvwb bv

nu¨v

bv

DËi w`‡Z

Abxnv

Rvwb bv

nu¨v

bv

DËi w`‡Z

Abxnv

Rvwb bv

nu¨v

bv

DËi w`‡Z

Abxnv

Rvwb bv

nu¨v

bv

DËi w`‡Z

Abxnv

Rvwb bv

nu¨v

bv

DËi w`‡Z

Abxnv

Rvwb bv

6d. gviv wM‡q‡Qb ev

wbnZ n‡q‡Qb?

nu¨v

bv

DËi w`‡Z

Abxnv

Rvwb bv

nu¨v

bv

DËi w`‡Z

Abxnv

Rvwb bv

nu¨v

bv

DËi w`‡Z

Abxnv

Rvwb bv

nu¨v

bv

DËi w`‡Z

Abxnv

Rvwb bv

nu¨v

bv

DËi w`‡Z

Abxnv

Rvwb bv

nu¨v

bv

DËi w`‡Z

Abxnv

Rvwb bv


B. gv`K I A¨vj‡Kvnj eënvi

w`‡bi DËi w`‡Z Rvwb bv

msL¨v Abxnv (RF) (DK)

1. MZ 30 w`‡b, Avcwb wb‡P DwjwLZ¸‡jv KZ w`b eënvi K‡i‡Qb:

a. †h †Kv‡bv A¨vj‡Kvnj [hw` k~b¨ nq, Zvn‡j mivmwi AvB‡Ug

B1cÑ†Z P‡j hvb|] |____|____|

b1. †bkv Kivi Rb¨ A¨vj‡Kvnj (GK êV‡K 5+ wW«sK) |____|____|

b2. †bkvi Rb¨ A¨vj‡Kvnj (GK êV‡K 4wU ev Zvi Kg wW«sK I

†bkv †eva Kiv) |____|____|

c. A‰ea gv`K [hw` B1a A_ev B1c = 0, DËi w`‡Z Abxnv (RF), ev

Rvwb bv (DK) nq Zvn‡j mivmwi AvB‡Ug B2Ñ†Z P‡j hvb|] |____|____|

d. A¨vj‡Kvnj Ges gv`K DfqB (GKB w`‡b) |____|____|

cª‡qvM c‡_i aib:

1. gy‡L 2. bv‡K 3. a~gcvb 4. wkivc‡_ bq Ggb Bb‡RKkb 5. wkiv

c‡_

*mvaviY cª‡qvM c_ D‡jL Ki“b| GKwUi †ewk cª‡qvM c‡_i Rb¨,

me‡P‡q ¸i“ZiwU D‡jL Ki“b| cª‡qvM c_¸‡jv ZvwjKvfz³ Kiv n‡q‡Q

me‡P‡q Kg ¸i“Zi (1) †_‡K me‡P‡q †ewk ¸i“Zi (5) wn‡m‡e|


[B2a †_‡K B2i ch©š— †Kv‡bv AvB‡U‡gi gvb 0ÑGi †P‡q eo n‡j,

B1cÑGi gvb Aek¨B 0ÑGi †P‡q eo n‡e|] w`‡bi cª‡qvM msL¨v RFDK c_* RF DK

a. †Kv‡KBb/µ¨vK |____|____| |____|

b. gvwiRyqvbv/nvwkk (cU, R‡q›U, ev›U, µwbK, DBW, †gwi,

†Rb) |____|____| |____|

c. Avwdg:

1. †n‡ivBb (¯§¨vK, GBP, RvsK, ¯‹¨vM) |____|____| |____|

2. giwdb |____|____| |____|

3. wWjyqvwWW |____|____| |____|

4. †W‡gij |____|____| |____|

5. cvi‡Kv‡mU |____|____| |____|

6. Wvifb |____|____| |____|

7. †Kv‡WBb |____|____| |____|

8. UvB‡jbj 2, 3, 4 |____|____| |____|

9. Aw·KbwUb/Aw·‡KvWb |____|____| |____| ‘

d. †cªmwµckbwenxb †g_v‡Wvb |____|____| |____|

e. `„wóåg m„wóKvix/Db¥v`RbK, PCP (A¨v‡Äj Wv÷, I‡Rvb,

Iq¨vK, i‡KU dz‡qj) MDMA (G·U¨vwm, XTC, G·, GWvg), LSD

(GwmW, eygvm©, B‡q‡jv mvbkvBb), gvki“g ev †gmKvwjb |____|____| |____|

f. †g_vg‡dUvwgb ev Ab¨ A¨vwçUvwgb (†g_, Avcvi, w¯úW,

AvBm, PK, wµ÷vj, Mvm, dvqvi, µ¨vsK) |____|____| |____|


B. gv`K I A¨vj‡Kvnj eënvi (µgkt)

cª‡qvM c‡_i aib:

1. gy‡L 2. bv‡K 3. a~gcvb 4. wkivc‡_ bq Ggb Bb‡RKkb 5. wkiv c‡_

*mvaviY cª‡qvM c_ D‡jL Ki“b| GKwUi †ewk cª‡qvM c‡_i Rb¨,

me‡P‡q ¸i“ZiwU D‡jL Ki“b| cª‡qvM c_¸‡jv ZvwjKvfz³ Kiv n‡q‡Q

me‡P‡q Kg ¸i“Zi (1) †_‡K me‡P‡q †ewk ¸i“Zi (5) wn‡m‡e|


[B2a †_‡K B2i ch©š— †Kv‡bv AvB‡U‡gi gvb 0ÑGi †P‡q eo n‡j,

B1cÑGi gvb Aek¨B 0ÑGi †P‡q eo n‡e|] w`‡bi cª‡qvM msL¨v RFDK c_* RF DK

g. 1. †eb‡RvWvqv‡Rwcb: Wvqv‡Rcvg (f¨vwjqvg);

Avjcªv‡Rvjvg (R¨vbv·); U«vqv‡Rvjvg (n¨vjwmqb); Ges

GmUv‡mvjvg (†cªvmg I †ivwncbjÑGQvovI i“wdm, †ivP, I

†Kvc bv‡gI cwiwPZ) |____|____| |____|

2. evwe©Pz‡iU: †g‡dvevwe©Uvj (†gevKvU); Ges

†c‡›Uvevwe©Uvj †mvwWqvg (†bgweDUvj) |____|____| |____|

3. †cªmwµckbÑwenxb GHB (wMªfvm& ewWwj nvg©;

wjKzBW G·U¨vwm; I RwR©qv †nvg eq bv‡g cwiwPZ) |____|____| |____|

4. †KUvwgb (†¯úkvj K ev wfUvwgb K bv‡g cwiwPZ) |____|____| |____|

5. Ab¨vb¨ cªkvwš—`vqK, D‡ËRbv cªkgbKvix, wb`ªvKviK ev

m‡¤§vnbx gv`K |____|____| |____|

h. wbtk¦v‡mi mv‡_ M„nxZ (ccvi, mœ¨vcvi, ivk, ûB‡cU) |____|____| |____|

i. Ab¨vb¨ A‰ea gv`K (D‡jL Ki“b) ______________________ |____|____| |____|

3. MZ 30 w`‡b, Avcwb wK Bb‡RKk‡bi gva¨‡g gv`K wb‡q‡Qb? [hw` B2a †_‡K B2i ch©š— Mªn‡Yi c_ = 4 ev 5 nq,

Zvn‡j, Aek¨B B3 = nu¨v n‡e|]

nu¨v

bv

DËi w`‡Z Abxnv

Rvwb bv

[hw` bv, DËi w`‡Z Abxnv, A_ev Rvwb bv nq, Zvn‡j mivmwi †mKkb CÑ†Z P‡j hvb|]

4. MZ 30 w`‡b, Avcwb KZ Nb Nb Ab¨ Kv‡iv eënvi Kiv wmwiÄ/muyB, KzKvi, Zzjv ev cvwb eënvi K‡i‡Qb?

me mgq

A‡a©‡Ki †ewk mgq

A‡a©K mgq

A‡a©‡Ki Kg mgq

KL‡bvB bq

DËi w`‡Z Abxnv

Rvwb bv


C. cwievi I emev‡mi Ae¯’v

1. MZ 30 w`‡b, Avcwb †ewkifvM mgq †Kv_vq emevm K‡i‡Qb? [K¬v‡q›U‡ì‡K DË‡ii Ackb¸‡jv c‡o †kvbv‡eb bv|]

Avkªq (wbivc` Avkªq [†md †n‡fb], µvwš—Kvjxb Avkªq †K›`ª [U«¨vbwRkbvj wjwfs †m›Uvi, wUGjwm], Kg

Pvwn`vhy³ ¯’vcbv, wi‡mckb †m›Uvi, Ab¨vb¨ A¯’vqx wèv ev mvÜ¨Kvjxb †K›`ª)

iv¯—v/AvDU‡Wvi (dzUcvZ, ìRvi mvg‡b, cvK©, miKvwi ev cwiZ¨³ feb)

cªwZôvb (nvmcvZvj, bvwm©s †nvg, †Rj/KvivMvi)

evmvq: [hw` evmvq nq, Zvn‡j h_vh_ Dcwefv‡M wUKwPý w`b:]

wbR¯^/fvov A¨vcvU©‡g›U, i“g, ev evwo

Ab¨ Kv‡iv A¨vcvU©‡g›U, i“g, ev evwo

W‡g©Uwi/K‡j‡Ri nj

nvdI‡q nvDm

AvevwmK wPwKrmv

Ab¨vb¨ ai‡bi AvevwmK (D‡jL Ki“b) _____________________________________________________

DËi w`‡Z Abxnv

Rvwb bv

2. MZ 30 w`‡b, Avcbvi A¨vj‡Kvnj ev Ab¨vb¨ gv`K eënvi Kivi Kvi‡Y Avcbvi Rb¨ wewfbœ welq¸‡jv KZUv

cxov`vqK wQj? [hw` B1a A_ev B1c > 0 nq, Zvn‡j C2 = Òcª‡hvR¨ bqÓ n‡Z cv‡i bv|]

G‡Kev‡iB bq

wKQzUv

D‡jL‡hvM¨fv‡e

AZ¨š—

cª‡hvR¨ bq [ïaygvÎ B1a Ges B1c = 0 n‡j eënvi Ki“b|]

DËi w`‡Z Abxnv

Rvwb bv

3. MZ 30 w`‡b, Avcbvi A¨vj‡Kvnj ev Ab¨vb¨ gv`K eënvi Kivi Kvi‡Y Avcbv‡K wK ¸i“Z¡c~Y© KvRKg©

Kwg‡q †dj‡Z ev †Q‡o w`‡Z n‡q‡Q? [hw` B1a A_ev B1c > 0 nq, Zvn‡j C3 = Òcª‡hvR¨ bqÓ n‡Z cv‡i bv|]

G‡Kev‡iB bq

wKQzUv


AZ¨š—


DËi w`‡Z Abxnv

Rvwb bv


C. cwievi I emev‡mi Ae¯’v (µgkt)

4. MZ 30 w`‡b, Avcbvi A¨vj‡Kvnj ev Ab¨vb¨ gv`K e¨envi Kivi Kvi‡Y Avcbvi wK Av‡eM m¤úwK©Z mgm¨v

n‡q‡Q? [hw` B1a A_ev B1c > 0 nq, Zvn‡j C4 = Òcª‡hvR¨ bqÓ n‡Z cv‡i bv|]

G‡Kev‡iB bq

wKQzUv


AZ¨š—


DËi w`‡Z Abxnv

Rvwb bv

5. [cyi“l bv n‡j] Avcwb wK eZ©gv‡b Mf©eZx?

nu¨v

bv

DËi w`‡Z Abxnv

Rvwb bv

6. Avcbvi wK †Q‡j‡g‡q Av‡Q?

nu¨v

bv

DËi w`‡Z Abxnv

Rvwb bv

[hw` bv, DËi w`‡Z Abxnv, A_ev Rvwb bv nq, Zvn‡j mivmwi †mKkb DÑ†Z P‡j hvb|]

a. Avcbvi KqwU †Q‡j‡g‡q Av‡Q? [hw` C6 = nu¨v nq, Zvn‡j C6a Gi gvb Aek¨B 0ÑGi †P‡q eo n‡e|]

|____|____| DËi w`‡Z Abxnv Rvwb bv

b. Av`vj‡Zi †Kv‡bv wkï myi¶v Av‡`‡ki Kvi‡Y Avcbvi †Kv‡bv †Q‡j‡g‡q wK Ab¨ Kv‡iv mv‡_ emevm

Ki‡Q?

nu¨v

bv

DËi w`‡Z Abxnv

Rvwb bv

[hw` bv, DËi w`‡Z Abxnv, A_ev Rvwb bv nq, Zvn‡j mivmwi AvB‡Ug C6d-†Z P‡j hvb|]

c. [hw` nu¨v nq] Av`vj‡Zi wkï myi¶v Av‡`‡ki Kvi‡Y Avcbvi KqwU †Q‡j‡g‡q Ab¨ Kv‡iv mv‡_

emevm Ki‡Q? [C6cÑGi gvb C6aÑGi gv‡bi †P‡q eo n‡Z cvi‡e bv|]


d. Avcbvi KqwU †Q‡j‡g‡qi Rb¨ Avcwb wcZ…‡Z¡i/gvZ…‡Z¡i AwaKvi nvwi‡q‡Qb? [K¬v‡q‡›Ui

wcZ…‡Z¡i/gvZ…‡Z¡i AwaKvi †K‡o †bIqv n‡q‡Q|] [AvB‡Ug C6dÑGi gvb C6aÑGi gv‡bi †P‡q eo n‡Z

cvi‡e bv|]



D. wk¶v, Kg©ms¯’vb, I Avq

1. Avcwb wK eZ©gv‡b †Kv‡bv ¯‹zj ev Kg©ms¯’vb cªwk¶Y Kg©m~wP‡Z fwZ© n‡q Av‡Qb? [hw` fwZ©

_v‡Kb] GUv wK c~Y©Kvjxb bvwK LÛKvjxb? [hw` K¬v‡q›U Kvivi“× _v‡Kb Zvn‡j D1ÑGi Rb¨ †KvW Ki“b

ÒfwZ© n‡q †bBÓ|]

fwZ© n‡q †bB

fwZ© n‡q Av‡Qb, c~Y©Kvjxb

fwZ© n‡q Av‡Qb, LÛKvjxb

Ab¨vb¨ (D‡jL Ki“b) _______________________________

DËi w`‡Z Abxnv

Rvwb bv

2. Avcwb †Kv‡bv wWMªx †c‡q _v‡Kb ev bv _v‡Kb, Avcwb m‡e©v”P †Kvb ch©v‡qi wk¶v m¤úbœ K‡i‡Qb?

KL‡bv ¯‹z‡j cwowb

1g †MªW

2q †MªW

3q †MªW

4_© †MªW

5g †MªW

6ô †MªW

7g †MªW

8g †MªW

9g †MªW

10g †MªW

11Zg †MªW

12Zg †MªW/nvB ¯‹zj wW‡cvgv/mggvb

K‡jR ev BDwbfvwm©wU/1g eQi m¤úbœ

K‡jR ev BDwbfvwm©wU/2q eQi m¤úbœ/mswkó wWMªx (AA, AS)

K‡jR ev BDwbfvwm©wU/3q eQi m¤úbœ

mœvZK wWMªx (BA, BS) ev D”PZi

nvB ¯‹z‡ji c‡i e„wËg~jK/KvwiMwi Kg©m~wP‡Z AskMªnY wKš‘ †Kv‡bv e„wËg~jK/KvwiMwi

wW‡cvgv †bB

nvB ¯‹z‡ji c‡i e„wËg~jK/KvwiMwi wW‡cvgv

DËi w`‡Z Abxnv

Rvwb bv

3. Avcwb wK eZ©gv‡b Kg©iZ? [MZ mßv‡ni †ewkifvM As‡ki Dci g‡bv‡hvM †`qvi gva¨‡g cwi®‹vi Ki“b †h,

K¬v‡q›U G‡Kev‡iB KvR K‡iwQ‡jb wKbv A_ev Zvi wbqwgZ PvKwi wQj wKbv hv †_‡K wZwb QzwU‡Z wQ‡jb|]

[hw` K¬v‡q›U D1ÑGi DË‡i e‡jb ÒfwZ© n‡q Av‡Qb, c~Y©KvjxbÓ Ges D3ÑGi DË‡i e‡jb Òc~Y©Kvjxb

PvKwiÓ, Zvn‡j GB welqwU e¨vL¨v Ki‡Z ejyb| hw` K¬v‡q›U Kvivi“× _v‡Kb Ges KvivMv‡ii evB‡i Zvi †Kv‡bv

KvR bv _v‡K, Zvn‡j D3ÑGi Rb¨ †KvW Ki“b Ò†eKvi, KvR LyuR‡Qb bvÓ|]

c~Y©Kvjxb PvKwiiZ (cªwZ mßv‡n 35+ N›Uv, A_ev KiwQ‡jb)

LÛKvjxb PvKwiiZ

†eKvi, KvR LyuR‡Qb

†eKvi, cªwZeÜx

†eKvi, †¯^”Qv‡mevg~jK KvR

†eKvi, Aemicªvß

†eKvi, KvR LyuR‡Qb bv

Ab¨vb¨ (D‡jL Ki“b) _____________________________________

DËi w`‡Z Abxnv

Rvwb bv


D. wk¶v, Kg©ms¯’vb, I Avq (µgkt)

4. MZ 30 w`‡b Avcwb wb‡P DwjwLZ iƒ‡c cªvq Kx cwigvY A_© †c‡q‡Qb (KiÑc~e© e¨w³MZ Avq)...

[hw` D3 =ÒPvKwiiZÓ bv nq Ges D4aÑGi gvb k~‡b¨i †P‡q eo nq, Zvn‡j wRÁvmv Ki“b| hw` D3 = Ò†eKvi, KvR

LyuR‡QbÓ nq Ges D4b = 0 nq, Zvn‡j wRÁvmv Ki“b| hw` D3 = Ò†eKvi, AemicªvßÓ nq Ges D4c = 0 nq, Zvn‡j

wRÁvmv Ki“b| hw` D3 = Ò†eKvi, cªwZeÜxÓ nq Ges D4d = 0 nq, Zvn‡j wRÁvmv Ki“b|]

RF DK

a. †eZb $ |__|__|__| , |__|__|__|

b. miKvwi mnvqZv $ |__|__|__| , |__|__|__|

c. Aemi fvZv $ |__|__|__| , |__|__|__|

d. cªwZeÜxZ¡ $ |__|__|__| , |__|__|__|

e. A‰ea Avq $ |__|__|__| , |__|__|__|

f. cwievi Ges/A_ev eÜz $ |__|__|__| , |__|__|__|

g. Ab¨vb¨ (D‡jL Ki“b) $ |__|__|__| , |__|__|__|

__________________

E. Aciva Ges Aciv‡ai wePv‡ii Ae¯’v

1. MZ 30 w`‡b, Avcwb KZevi †Mªßvi n‡q‡Qb?

|____|____| evi DËi w`‡Z Abxnv Rvwb bv

[hw` GKeviI †Mªßvi bv nb, Zvn‡j mivmwi AvB‡Ug E3Ñ†Z P‡j hvb|]

2. MZ 30 w`‡b, Avcwb gv`KÑmswkó Kvi‡Y KZevi †Mªßvi n‡q‡Qb? [E2ÑGi gvb E1ÑGi †P‡q eo n‡Z cvi‡e

bv|]

|____|____| evi DËi w`‡Z Abxnv Rvwb bv

3. MZ 30 w`‡b, Avcwb KZ ivZ nvR‡Z/KvivMv‡i wQ‡jb? [hw` E3ÑGi gvb 15ÑGi †P‡q eo nq, Zvn‡j Aek¨B C1

= cªwZôvb (nvRZ/KvivMvi) n‡e| hw` C1 = cªwZôvb (nvRZ/KvivMvi) nq, Zvn‡j E3ÑGi gvb Aek¨B 15 Gi mgvb ev

Zvi‡P‡q eo n‡e|]

|____|____| ivZ DËi w`‡Z Abxnv Rvwb bv

4. MZ 30 w`‡b, Avcwb KZevi Aciva K‡i‡Qb? [KZ w`b A‰ea gv`K MªnY K‡i‡Qb Zv c„ôv 7ÑGi AvB‡Ug

B1cÑ†Z †`Lyb| GLv‡b E4ÑGi DËi B1cÑGi msL¨vi mgvb ev Zvi‡P‡q eo n‡e KviY A‰ea gv`K e¨envi Kiv GKUv

Aciva|]

|____|____|____| evi DËi w`‡Z Abxnv Rvwb bv

5. Avcwb wK eZ©gv‡b Awfhy³ nIqv, wePv‡ii m¤§zLxb nIqv, ev `Û cvIqvi Rb¨ A‡c¶v Ki‡Qb?

nu¨v

bv

DËi w`‡Z Abxnv

Rvwb bv

6. Avcwb wK eZ©gv‡b c¨v‡iv‡j ev cª‡ek‡b Av‡Qb?

nu¨v

bv

DËi w`‡Z Abxnv

Rvwb bv


F. gvbwmK I kvixwiK ¯^v‡¯’ï mgm¨v Ges wPwKrmv/wbivgq

1. GB gyû‡Z© Avcbvi mvwe©K ¯^v¯’¨‡K Avcwb Kxfv‡e g~j¨vqb Ki‡eb?

PgrKvi

Lye fv‡jv

fv‡jv

†gvUvgywU

Lvivc

DËi w`‡Z Abxnv

Rvwb bv

2. MZ 30 w`‡b, Avcwb wK wb‡P DwjwLZ¸‡jv †c‡q‡Qb:

a. wb‡P DwjwLZ¸‡jvi Rb¨ nvmcvZv‡j

fwZ© †_‡K wPwKrmv:

nu¨v

[hw` nu¨v nq] me wgwj‡q †gvU KZ

ivZ bv RF DK

i. kvixwiK Amy¯’Zv _________ ivZ

ii. gvbwmK ev Av‡eMMZ mgm¨v _________ ivZ

iii. A¨vj‡Kvnj ev gv`‡Ki Aceënvi _________ ivZ

b. wb‡P DwjwLZ¸‡jvi Rb¨ ewnwe©fvM

†_‡K wPwKrmv:

nu¨v

[hw` nu¨v nq]

me wgwj‡q †gvU KZ

ivZ bv RF DK

i. kvixwiK Amy¯’Zv _________ evi

ii. gvbwmK ev Av‡eMMZ mgm¨v _________ evi

iii. A¨vj‡Kvnj ev gv`‡Ki Aceënvi _________ evi

c. wb‡P DwjwLZ¸‡jvi Rb¨ Ri“wi

wefv‡Mi wPwKrmv:

nu¨v

[hw` nu¨v nq]

me wgwj‡q †gvU KZ

ivZ bv RF DK

i. kvixwiK Amy¯’Zv _________ evi

ii. gvbwmK ev Av‡eMMZ mgm¨v _________ evi

iii. A¨vj‡Kvnj ev gv`‡Ki Aceënvi _________ evi


F. gvbwmK I kvixwiK ¯^v‡¯’¨i mgm¨v Ges wPwKrmv/wbivgq (µgkt)

3. MZ 30 w`‡b, Avcwb wK †hŠbK‡g© RwoZ n‡q‡Qb?

nu¨v

bv → [mivmwi F4ÑG P‡j hvb|]

wRÁvmv Kivi Rb¨ Aby‡gvw`Z bq → [mivmwi F4ÑG P‡j hvb|]

DËi w`‡Z Abxnv → [mivmwi F4ÑG P‡j hvb|] Rvwb bv → [mivmwi F4ÑG P‡j hvb|]

[hw` nu¨v nq] me wgwj‡q, KZ evi:

msmM©© RF DK

a. Avcwb wK †hŠb msmM© (†hvwbc‡_, gy‡L, ev cvqyc‡_)

K‡i‡Qb? |____|____|____|

b. Avcwb wK Aiw¶Z †hŠb msmM© K‡i‡Qb? [F3bÑGi gvb

F3aÑGi gv‡bi †P‡q eo n‡Z cvi‡e bv|] [hw` k~b¨ nq, Zvn‡j

F4ÑG P‡j hvb|] |____|____|____|

c. Ggb GKRb e¨w³i mv‡_ Aiw¶Z †hŠb msmM© K‡i‡Qb hvi

eZ©gvb ev AZx‡Zi Ae¯’v n‡”Q: [F3c1 †_‡K F3c3 ch©š—

†KvbwUi gvb F3bÑGi gv‡bi †P‡q eo n‡Z cvi‡e bv|]

1. HIV c‡RwUf ev GBWm Av‡Q |____|____|____|

2. Bb‡RKk‡bi gva¨‡g gv`K e¨enviKvix |____|____|____|

3. wKQz wKQz gv`K MªnY K‡i †bkv K‡ib |____|____|____|

4. Avcwb Kx KL‡bv HIVÑGi cix¶v Kwi‡q‡Qb?

nu¨v ......................... [F4aÑ†Z P‡j hvb|]

bv ............................ [mivmwi F5ÑG P‡j hvb|]

DËi w`‡Z Abxnv .... [mivmwi F5ÑG P‡j hvb|]

Rvwb bv ................. [mivmwi F5ÑG P‡j hvb|]

4a. Avcwb wK Avcbvi HIV cix¶vi djvdj Rv‡bb?

nu¨v

bv



5. MZ 30 w`‡b, Avcbvi A¨vj‡Kvnj ev gv`K e¨envi bv Kivi Kvi‡Y, Avcwb KZ w`b:

w`b RF DK

a. gvivZ¥K welbœZvq fz‡M‡Qb |____|____|

b. gvivZ¥K `ywðš—v ev D‡ËRbvq fz‡M‡Qb |____|____|

c. `„wóweå‡g fz‡M‡Qb |____|____|

d. eyS‡Z, g‡bv‡hvM w`‡Z, ev g‡b ivL‡Z mgm¨vq c‡o‡Qb |____|____|

e. wnsmª AvPiY wbqš¿Y Ki‡Z Amyweavq c‡o‡Qb |____|____|

f. AvZ¥nZ¨vi †Póv K‡i‡Qb |____|____|

g. gvbwmK/Av‡eMMZ mgm¨vi Kvi‡Y Ily‡ai †cªmwµckb

†c‡q‡Qb |____|____|

[hw` cªkœ 5ÑGi me¸‡jv AvB‡U‡gi DË‡i K¬v‡q›U k~b¨ w`b, RF ev DK wi‡cvU© K‡ib, Zvn‡j mivmwi AvB‡Ug

F7 G P‡j hvb|]

6. MZ 30 w`‡b GB me gvbwmK ev Av‡eMMZ mgm¨vi Kvi‡Y Avcwb KZUv Amyweavq c‡owQ‡jb?

G‡Kev‡iB bq

wKQzUv

†gvUvgywU


AZ¨š—

DËi w`‡Z Abxnv

Rvwb bv

mwnsmZv I gvbwmK AvNvZ

7. Avcwb Kx KL‡bv †Kv‡bv cwi‡e‡k mwnsmZv ev gvbwmK AvNv‡Zi m¤§zLxb n‡qwQ‡jb (Gi g‡a¨ i‡q‡Q

KwgDwbwU‡Z ev ¯‹z‡j mwnsmZv; cvwievwiK mwnsmZv; cwiev‡ii †fZ‡i ev evB‡i kvixwiK, gvbwmK, ev

†hŠb Ace¨envi/AvµgY; cªvK…wZK `y‡h©vM; mš¿vmev`; Ae‡njv; ev gvbwmK AvNvZRwbZ `ytL?)

nu¨v

bv [mivmwi AvB‡Ug F8 G P‡j hvb|]

DËi w`‡Z Abxnv

Rvwb bv

[hw` bv, DËi w`‡Z Abxnv, ev Rvwb bv nq, Zvn‡j AvB‡Ug mivmwi F8 G P‡j hvb|]



GB AwfÁZv¸‡jvi †Kv‡bvwU Kx GZUv fxwZKi, fqvbK, ev wech©qKi wQj †h, AZx‡Z Ges/A_ev eZ©gv‡b,

Avcwb:

7a. GwU m¤ú‡K© `yt¯^cœ †`‡LwQ‡jb ev Avcwb hLb Pvbwb ZL‡bv GwU m¤ú‡K© wPš—v

K‡iwQ‡jb?

nu¨v

bv

DËi w`‡Z Abxnv

Rvwb bv

7b. GwU m¤ú‡K© wPš—v bv Kivi Rb¨ K‡Vvifv‡e †Póv K‡iwQ‡jb A_ev Avcbv‡K Gi K_v g‡b Kwi‡q

†`q GB iKg cwiw¯’wZ Gov‡bvi Rb¨ cªej †Póv K‡iwQ‡jb?

nu¨v

bv

DËi w`‡Z Abxnv

Rvwb bv

7c. µgvMZfv‡e mZK© wQ‡jb, ch©‡e¶Y KiwQ‡jb, ev mn‡RB Pg‡K DVwQ‡jb?

nu¨v

bv

DËi w`‡Z Abxnv

Rvwb bv

7d. Ab¨ †jvKRb, Kg©KvÛ, ev Avcbvi Pvicvk †_‡K wew”Qbœ ev Abyf‚wZk~b¨ †eva KiwQ‡jb?

nu¨v

bv

DËi w`‡Z Abxnv

Rvwb bv

8. MZ 30 w`‡b, Avcwb KZ Nb Nb AvNvZ, jvw_, ev Po †L‡q‡Qb, A_ev Ab¨ †Kv‡bvfv‡e kvixwiKfv‡e AvNvZ

†c‡q‡Qb?

KL‡bvB bq

K‡qK evi

K‡qK ev‡ii †P‡q †ewk

DËi w`‡Z Abxnv

Rvwb bv


G. mvgvwRK †hvM‡hvM

1. MZ 30 w`‡b, Avcwb wK wbivg‡qi Rb¨ Ggb †Kv‡bv †¯^”Qv‡mex ¯^q¤¢i †Mvôx‡Z AskMªnY K‡i‡Qb hv

†Kv‡bv ag©xq ev wek¦vmÑwfwËK msMV‡bi mv‡_ m¤ú„³ wQj bv? Ab¨ K_vq ejv hvq, Avcwb wK †Kv‡bv

AÑ†ckv`vi, m½xÑcwiPvwjZ msMV‡b AskMªnY K‡i‡Qb hv Ggb gvbyl‡ì‡K mvnvh¨ Kivi Rb¨ wb‡ew`Z

hv‡ì gv`Kvmw³ mswkó mgm¨v Av‡Q, †hgb: A¨vj‡KvnwjKm& A¨v‡bvwbgvm, bvi‡KvwUKm&

A¨v‡bvwbgvm, A·‡dvW© nvDm, †mKzjvi AM©vbvB‡Rkb di meiv‡qwU, ev DB‡gb di meiv‡qwU,

BZ¨vw`?

nu¨v [hw` nu¨v nq] D‡jL Ki“b KZ evi |____|____| DËi w`‡Z Abxnv Rvwb bv

bv

DËi w`‡Z Abxnv

Rvwb bv

2. MZ 30 w`‡b, Avcwb wK †Kv‡bv ag©xq/wek¦vm wfwËK wbivgq ¯^q¤¢i †Mvôx‡Z AskMªnY K‡i‡Qb?


bv

DËi w`‡Z Abxnv

Rvwb bv

3. MZ 30 w`‡b, Avcwb wK Dc‡i DwjwLZ msMVb¸‡jv Qvov Ab¨ †Kv‡bv msMV‡bi mfvq †hvM w`‡q‡Qb

hviv wbivg‡q mvnvh¨ K‡i?


bv

DËi w`‡Z Abxnv

Rvwb bv

4. MZ 30 w`‡b, Avcbvi cwiev‡ii †Kv‡bv m`m¨ Ges/A_ev eÜz‡ì mv‡_ wK Avcbvi †hvMv‡hvM n‡q‡Q hviv

Avcbvi wbivg‡q mnvqZv Ki‡Z Pvb?

nu¨v

bv

DËi w`‡Z Abxnv

Rvwb bv

5. Avcwb mgm¨vq co‡j Kvi Kv‡Q hvb? [ïaygvÎ GKwU wbe©vPb Ki“b|]

Kv‡iv Kv‡Q bq

ag©xq †bZv

cwiev‡ii m`m¨

eÜz

DËi w`‡Z Abxnv

Rvwb bv

Ab¨vb¨ (D‡jL Ki“b) _______________________________


I. d‡jvAv‡ci Ae¯’v

[ïaygvÎ d‡jvAv‡ci mgq K¬v‡q›U m¤ú‡K© Kg©m~wPi Kg©x‡`i Øviv wi‡cvU©K…Z|]

1. K¬v‡q‡›Ui d‡jvAv‡ci Ae¯’v Kx? [GwU GKwU Avek¨K AvB‡Ug: cª‡hvR¨ bq, DËi w`‡Z Abxnv, Rvwb bv, Ges

†bB, MªnY Kiv n‡e bv]

01 = wba©vwiZ mg‡qi Av‡M gviv †M‡Qb

11 = wba©vwiZ mg‡qi g‡a¨ mv¶vrKvi m¤úbœ K‡i‡Qb

12 = wba©vwiZ mg‡qi evB‡i mv¶vrKvi m¤úbœ K‡i‡Qb

21 = Ae¯’vb Rvbv †M‡Q, wKš‘ Abxnv cªKvk K‡i‡Qb, mywbw`©ó bq

22 = Ae¯’vb Rvbv †M‡Q, wKš‘ cªwZôv‡b cª‡e‡ki my‡hvM cvIqv hvqwb

23 = Ae¯’vb Rvbv †M‡Q, wKš‘ Ab¨ †Kv‡bv Kvi‡Y †`Lv Kivi my‡hvM cvIqv hvqwb

24 = Ae¯’vb Rvbv †M‡Q, wKš‘ cªKí †_‡K wb‡R‡K cªZ¨vnvi K‡i‡Qb

31 = Ae¯’vb Rvbv hvqwb, ¯’vb e`j K‡i‡Qb

32 = Ae¯’vb Rvbv hvqwb, Ab¨vb¨ (D‡jL Ki“b) ________________________

2. K¬v‡q›U wK GL‡bv Avcbvi Kg©m~wP †_‡K †mev cv‡”Qb?

nu¨v

bv

[hw` GUv GKUv d‡jvAvc mv¶vrKvi nq, Zvn‡j GLb eÜ Ki“b; mv¶vrKvi †kl n‡q‡Q|]


J. wWmvPv‡R©i Ae¯’v

[ïaygvÎ wWmPv‡R©i mgq K¬v‡q›U m¤ú‡K© Kg©m~wPi Kg©x‡ì Øviv wi‡cvU©K…Z]

1. K¬v‡q›U‡K K‡e wWmPvR© Kiv n‡q‡Q?

|____|____| / |____|____| / |____|____|____|____|

gvm w`b eQi

2. K¬v‡q‡›Ui wWmPv‡R©i Ae¯’v Kx?

01 = m¤úbœ/DËxY©

02 = LvwiR

hw` K¬v‡q›U‡K LvwiR Kiv nq, Zvn‡j Lvwi‡Ri KviY Kx wQj? [GKwU DËi wbe©vPb Ki“b|]

01 = Kg©x‡ì civg‡k©i wei“‡× wbR B”Qvq P‡j †M‡Qb, m‡š—vlRbK AMªMwZ wQj

02 = Kg©x‡ì civg‡k©i wei“‡× wbR B”Qvq P‡j †M‡Qb, m‡š—vlRbK AMªMwZ QvovB

03 = AskMªnY bv Kivi Kvi‡Y B”Qvi wei“‡× LvwiR Kiv n‡q‡Q

04 = wbqgÑKvbyb f½ Kivi Kvi‡Y B”Qvi wei“‡× LvwiR Kiv n‡q‡Q

05 = Ab¨ †Kv‡bv Kg©m~wP ev Ab¨ cwi‡levi Rb¨ mycvwik Kiv n‡q‡Q, m‡š—vlRbK AMªMwZ wQj

06 = Ab¨ †Kv‡bv Kg©m~wP ev Ab¨ cwi‡levi Rb¨ mycvwik Kiv n‡q‡Q, m‡š—vlRbK AMªMwZ wQj bv

07 = wPwKrmv/wbqvgqKvjxb mg‡q K…Z Aciv‡ai Rb¨ Kvivi“× n‡q‡Qb, m‡š—vlRbK AMªMwZ wQj

08 = wPwKrmv/wbqvgqKvjxb mg‡q K…Z Aciv‡ai Rb¨ Kvivi“× n‡q‡Qb, m‡š—vlRbK AMªMwZ wQj

bv

09 = wPwKrmv/wbqvgq Kvh©µ‡g cª‡e‡ki Av‡M K…Z Aciv‡ai c‡ivqvbv ev Awf‡hv‡Mi Rb¨ Kvivi“×

n‡q‡Qb, m‡š—vlRbK AMªMwZ wQj

10 = wPwKrmv/wbqvgq Kvh©µ‡g cª‡e‡ki Av‡M K…Z Aciv‡ai c‡ivqvbv ev Awf‡hv‡Mi Rb¨ Kvivi“×

n‡q‡Qb, m‡š—vlRbK AMªMwZ wQj bv

11 = ¯^v¯’¨MZ Kvi‡Y Av‡iKwU cªwZôv‡b ¯’vbvš—i Kiv n‡q‡Q

12 = g„Z¨z

13 = Ab¨vb¨ (D‡jL Ki“b) ______________________________

3. Kg©m~wPwU wK GB K¬v‡q‡›Ui HIVÑGi cix¶v K‡i‡Q?

nu¨v [mivmwi †mKkb KÑ†Z P‡j hvb|]

bv [J4ÑG hvb|]

4. [hw` bv nq] Kg©m~wPwU wK GB K¬v‡q›U‡K GB cix¶vi Rb¨ civgk© w`‡q‡Q?

nu¨v

bv


K. M„nxZ †mevmg~n

[ïaygvÎ wWmPv‡R©i mgq K¬v‡q›U m¤ú‡K© Kg©m~wPi Kg©x‡ì Øviv wi‡cvU©K…Z]

K¬v‡q‡›Ui wPwKrmv/Av‡ivM¨jv‡fi mg‡q

K¬v‡q›U‡K KZ w`b cwi‡lev †`qv n‡q‡Q Zv D‡jL

Ki“b| [†Kv‡bv cwi‡lev †`qv bv n‡j k~b¨ wjLyb|

wPwKrmvi ai‡bi Rb¨ Avcbvi Kgc‡¶ GK w`b _vK‡Z

n‡e|]

wPwKrmvi aib w`b

1. †Km eë¯’vcbv |___|___|___|

2. wèvKvjxb wPwKrmv |___|___|___|

3. fwZ© nIqv †ivMx/nvmcvZvj

(gv`Kvkw³ wbivgq e¨ZxZ) |___|___|___|

4. ewnwe©fvMxq †ivMx |___|___|___|

5. AvDUwiP |___|___|___|

6. wbweo ewnwe©fvMxq †ivMx |___|___|___|

7. †g_v‡Wvb |___|___|___|

8. AvevwmK/cybe©vmb |___|___|___|

9. gv`Kvkw³ wbivgq (ïay GKwU †e‡Q

wbb):

A. nvmcvZv‡j fwZ© nIqv †ivMx |___|___|___|

B. wd« ÷¨vwÛs AvevwmK |___|___|___|

C. ewnwe©fvMxq †ivMx‡ì gv`Kvkw³

wbivgq |___|___|___|

10. cieZ©x cwiPh©v |___|___|___|

11. wbivg‡q mnvqZv |___|___|___|

12. Ab¨vb¨ (D‡jL Ki“b) ____________ |___|___|___|

K¬v‡q‡›Ui wPwKrmv/Av‡ivM¨jv‡fi mg‡q

K¬v‡q›U‡K KqwU †mkb †`qv n‡q‡Q Zv D‡jL

Ki“b| [†Kv‡bv cwi‡lev †`qv bv n‡j k~b¨ wjLyb|]

wPwKrmv †mev †mkb

[SBIRT gÄzwi: 1 †_‡K 4 ch©š— GKwU wPwKrmv

†mevi Rb¨ Avcbvi Kgc‡¶ GKwU †mkb _vK‡Z n‡e|]

1. w¯Œwbs |___|___|___|

2. msw¶ß n¯—‡¶c |___|___|___|

3. msw¶ß wPwKrmv |___|___|___|

4. wPwKrmvi Rb¨ †idvi Kiv |___|___|___|

5. g~j¨vqb |___|___|___|

6. wPwKrmv/wbivg‡qi cwiKíbv |___|___|___|

7. e¨w³MZ civgk© †mev |___|___|___|

8. `jMZ civgk© †mev |___|___|___|

9. cvwievwiK/êevwnK civgk© |___|___|___|

10. hyMcr wPwKrmv/wbivgq †mev |___|___|___|

11. IlyawfwËK n¯—‡¶c |___|___|___|

12. HIV/GBWm m¤úwK©Z civgk© |___|___|___|


(D‡jL Ki“b)___________________ |___|___|___|

†Km eë¯’vcbv cwi‡lev †mkb

1. cvwievwiK †mev (we‡q msµvš—

wk¶v, wcZ…Z¡/gvZ…Z¡, wkï

Dbœqb †mev mn) |___|___|___|

2. wkï cwiPh©v |___|___|___|

3. Kg©ms¯’vb msµvš— †mev

A. cªvKÑKg©ms¯’vb |___|___|___|

B. Kg©ms¯’vb msµvš— †KvwPs |___|___|___|

4. e¨w³MZ cwi‡levi mgš^q |___|___|___|

5. cwienb |___|___|___|

6. HIV/GBWm welqK cwi‡lev |___|___|___|

7. mnvqZvg~jK µvwš—Kvjxb

gv`KÑgy³ Avevmb †mev |___|___|___|

8. Ab¨vb¨ †Km eë¯’vcbv cwi‡lev

(D‡jL Ki“b) __________________ |___|___|___|

wPwKrmv †mev †mkb

1. wPwKrmv cwiPh©v |___|___|___|

2. A¨vj‡Kvnj/gv`K cix¶v |___|___|___|

3. HIV/GBWm wPwKrmv mnvqZv I

cix¶v |___|___|___|


(D‡jL Ki“b) __________________ |___|___|___|

cwiPh©v cieZ©x †mev †mkb

1. Ae¨vnZ cwiPh©v |___|___|___|

2. cybivq wjß nIqv cªwZ‡iva |___|___|___|

3. wbivg‡qi †KvwPs |___|___|___|

4. ¯^q¤¢i †Mvôx I mnvqZv `j |___|___|___|

5. Ava¨vwZ¥K mnvqZv |___|___|___|

6. Ab¨vb¨ cwiPh©v cieZ©x †mev

(D‡jL Ki“b) __________________ |___|___|___|

wk¶v cwi‡lev †mkb

1. gv`‡Ki Aceënvi m¤úwK©Z wk¶v |___|___|___|

2. HIV/GBWm m¤úwK©Z wk¶v |___|___|___|

3. Ab¨vb¨ wk¶v cwi‡lev

(D‡jL Ki“b) __________________ |___|___|___|

m½xiÑØvivÑm½xi wbivgq mnvqZv

cwi‡lev †mkb

1. m½x‡ì †KvwPs ev civgk© |___|___|___|

2. evm¯’vb mnvqZv |___|___|___|

3. A¨vj‡KvnjÑ I gv`KÑgy³ mgvRKg© |___|___|___|

4. Z_¨ I mycvwik |___|___|___|

5. m½xiÑØvivÑm½xi Ab¨vb¨ wbivgq

mnvqZv †mev

(D‡jL Ki“b) __________________ |___|___|___|

csat gpra k¬v‡q›u djvdj †¯^”qvaxb kg©m~wp¸‡jvi rb¨ c`‡¶cmg ... · dig aby‡gvw`z...

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