Form 2-HAB_CL

Health Resources and Services Administration (HRSA)
Ryan White HIV/AIDS Program Client-Level Data Report

PROVIDER FORM

Items 1 – 2 (display only): These items contain information saved in the
Ryan White Client-level Data System (CLDS). To edit this information,
providers must update their organization and user profiles in the CLDS.
Item 3: Select the provider type that best describes the organization. After
the initial submission, this item will be pre-populated in subsequent data
reports.
Item 4: Indicate if your organization received funding under Section 330 of
the Public Health Service Act during the given reporting period.

Last saved by: Maria Jackson Hittle
Last saved at: 5/27/2008 1:20 PM

Item 5: Select the category that best describes your organization’s
ownership status. If “Private, nonprofit” is selected, you must answer Item
5b. After the initial submission, this item will be pre-populated in
subsequent data reports.
Item 6: Indicate if your organization received Minority AIDS Initiative
(MAI) funds during the given reporting period.
Item 7: Enter the amount of Ryan White Program funds expended on oral
health care during the given reporting period.

Page 1 of 8

Health Resources and Services Administration (HRSA)
Ryan White HIV/AIDS Program Client-Level Data Report

PROVIDER FORM

Item 8: Grantee/contract information: This list of contracts is populated
with information provided by Ryan White HIV/AIDS Program grantees.
The contract reference, if specified, will help you report the data associated
with a particular contract. (Note: For the purposes of the Ryan White Data
Report, “contracts” include formal contracts, memorandum of
understanding, and other agreements.)
Services: This link opens another screen (see pages 5 – 8). Select the
services delivered under each agreement during the given reporting period.

Last saved by: Maria Jackson Hittle
Last saved at: 5/27/2008 1:20 PM

Item 9: Select the categories that best describe your organization.
Item 10: Report the number of paid staff, in full-time equivalents (FTEs),
funded by the Ryan White HIV/AIDS Program during the given reporting
period.
Item 11: Select the status of your agency’s clinical quality management
program.

Page 2 of 8

Health Resources and Services Administration (HRSA)
Ryan White HIV/AIDS Program Client-Level Data Report

PROVIDER FORM

Items 12–17: If a grantee indicates that your organization was contracted to provide HIV counseling and testing services during the given reporting period, your
organization must complete this section.

Last saved by: Maria Jackson Hittle
Last saved at: 5/27/2008 1:20 PM

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Health Resources and Services Administration (HRSA)
Ryan White HIV/AIDS Program Client-Level Data Report

PROVIDER FORM

Grantees and/or providers have the option of importing provider data into the CLDS from their local system. The XML provider file includes:
• Provider organizational data (Items 3 – 7 and 9 – 11)
• Services provided with Ryan White funds under each agreement (Item 8)
• HIV counseling and testing data (Item 12 – 17)
In order to complete their submission, grantees must ensure that their providers’ client-level data, if appropriate, are imported into the CLDS. The XML client
file includes the proposed client-level data fields.

Last saved by: Maria Jackson Hittle
Last saved at: 5/27/2008 1:20 PM

Page 4 of 8

Health Resources and Services Administration (HRSA)
Ryan White HIV/AIDS Program Client-Level Data Report

PROVIDER FORM— SERVICES

Please select administrative and technical services delivered under this agreement during the given reporting period (check all that apply).

Last saved by: Maria Jackson Hittle
Last saved at: 5/27/2008 1:20 PM

Page 5 of 8

Health Resources and Services Administration (HRSA)
Ryan White HIV/AIDS Program Client-Level Data Report

PROVIDER FORM— SERVICES

Please select the core medical services delivered under this agreement during the given reporting period (check all that apply).

Last saved by: Maria Jackson Hittle
Last saved at: 5/27/2008 1:20 PM

Page 6 of 8

Health Resources and Services Administration (HRSA)
Ryan White HIV/AIDS Program Client-Level Data Report

PROVIDER FORM— SERVICES

Please select the support services delivered under this agreement during the given reporting period (check all that apply).

Last saved by: Maria Jackson Hittle
Last saved at: 5/27/2008 1:20 PM

Page 7 of 8

Health Resources and Services Administration (HRSA)
Ryan White HIV/AIDS Program Client-Level Data Report

PROVIDER FORM— SERVICES

Please indicate if you delivered HIV counseling and testing services under this agreement during the given reporting period.

Last saved by: Maria Jackson Hittle
Last saved at: 5/27/2008 1:20 PM

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