PWN+ is an organization formed by women living with HIV/AIDS (WLHA) in October 1998 to address the need for a support system and to improve the quality of life of women living with HIV and their children in India. Membership is open to all women living with HIV in India. If you are willing to become a member of PWN+, you should pay annual membership fee of Rs. 120/ as per the byelaws.
Name of spouse / parent :
mail-id :
Age :
Date of Birth :
Religion :
Caste :
Education :
Languages Known :
Read
WriteSpeak
Understand
Read
WriteSpeak
Understand
Read
WriteSpeak
Understand
Read
WriteSpeak
Understand
Any special skills :
Occupation :
Monthly income :
Status :
MarriedUnmarried
Widowed
Abandoned
Drug user
Currently Residing with :
Family Details
S.No Adults
Relationship to member
Age
Education
Occupation
HIV Status
Children
Address for communication :
Date of HIV diagnosis(year) :
Place for diagnosis :
Reason for HIV testing :
Did you receive pre-test counselling :
YesNo
Did you receive post-test counselling :
YesNo
ARV Details
Are you on ARV therapy as on date? :
YesNo
Date of initiation :
Combination/medicines(current) :
prescribed by/consultant doctor :
Govt/private :
Place :
State :
Children
Educational details
Name of Child
Class
School(Govt/Pvt)
Education
ARV details - if on ARV :
Name of Child
Age
Date of intiation of ARV
Specific regimen
Consultant doctor
ARV expendituremet by
Have you ever faced any discrimination due to HIV? :
yes
NO
How did you come to know about PWN+? :
Interest to participate in network activities :
Participate in support group activities
Speak in media(TV/radio)
Speak in public meetings
Bring other WLHA to PWN+
Consent for giving for PWN+ publication
Any other
Iam willing to become a member of POSITIVE WOMEN NETWORK