Form 1 Ryan White HIV/AIDS Program Data Report

2010 Ryan White HIV/AIDS Program Data Report

Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this project is 0915-0253, and the expiration date is 02/28/2011. Public reporting burden for this collection of information is estimated to average 33 hours per respondent annually, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 10-33, Rockville, Maryland, 20857.

Revised: November 1, 2010

HIV/AIDS Bureau

Division of Science and Policy

Health Resources and Services Administration

5600 Fishers Lane, Room 7-90

Rockville, MD 20857

Section 1.SerVICE PROVIDER Information

Section 1 (Items 1–22) should be completed by all service providers funded through Title XXVI of the Public Health Service Act as amended by the Ryan White HIV/AIDS Treatment Modernization Act of 2006 (Ryan White HIV/AIDS Program) Parts A, B, C, and D. For the definition of service provider, please refer to the instructions for completing this form.

Section 1.1 Provider and Agency Contact Information

1. Provider name:

2. Provider address:

2. Street:

3. City: State:

4. ZIP Code: __ __ __ __ __ - __ __ __ __

5. Taxpayer ID #: __ __ - __ __ __ __ __ __ __

3. Contact information:

1. Name:

2. Title:

3. Phone #: (__ __ __) __ __ __ - __ __ __ __

4. Fax #: (__ __ __) __ __ __ - __ __ __ __

5. E-mail:

4. Person completing this form:

1. Name:

2. Phone #: (__ __ __) __ __ __ - __ __ __ __

3. E-mail:

Section 1.2 Reporting and Program Information

5. Calendar year for reporting: (mm/dd/yyyy)

Start date: __ __ / __ __ / __ __ __ __

End date: __ __ / __ __ / __ __ __ __

6. Reporting scope: __ __ (Select only one.)

01 = ALL clients receiving a service ELIGIBLE for Part A, B, C, or D funding

02 = ONLY clients receiving a Part A, B, C, or D FUNDED service

Remember: Grantees and providers using reporting scope “02” must have an adequate mechanism for tracking clients and services by funding stream. Providers using reporting scope "02" must have secured prior approval from their grantee in consultation with their HRSA project officer. All subsequent Items regarding “clients” should be answered relative to the reporting scope you select here.

7. Provider type:

1. (Select only one.)

 Hospital or university-based clinic

 Publicly funded community health center

 Publicly funded community mental health center

 Other community-based service organization (CBO)

 Health department

 Substance abuse treatment center

 Solo/group private medical practice

 Agency reporting for multiple fee-for-service providers

 PLWHA coalition

 VA facility

 Other facility (Specify )

2. Did you receive funding under Section 330 of the Public Health Service Act (funds community health centers, migrant health centers, and health care for the homeless) during this reporting period?

 Yes  No  Don’t know/unsure

8. Ownership status:

1. (Select only one.)

 Public/local

 Public/State

 Public/Federal

 Private, nonprofit (Go to Item 8b)

 Private, for-profit

 Unincorporated

 Other

2. If “Private, nonprofit” was selected in Item 8a, is your organization faith-based?

 Yes  No

9. Did your organization expend Minority AIDS Initiative (MAI) funds during this reporting period?

 Yes  No  Don’t know/unsure

10. Source of Ryan White HIV/AIDS Program funding: (Check all that apply.)

 Part A

Name of grantee(s):

1.

2.

3.

 Part B

Name of grantee(s):

1.

2.

3.

 Part C EIS

Name of grantee(s):

1.

2.

3.

 Part D (including the Adolescent Initiative)

Name of grantee(s):

1.

2.

3.

11. Part A funding

1. Total amount of Part A funding expended during this reporting period (rounded to the nearest dollar):

$

2. Of the amount in Item 11a, how much is from the Minority AIDS Initiative (rounded to the nearest dollar):

$

12. Part B funding

1. Total amount of Part B funding expended during this reporting period (rounded to the nearest dollar):

$

2. Of the amount in Item 12a, how much is from the Minority AIDS Initiative (rounded to the nearest dollar)?

$

13. Part C EIS funding

1. Total amount of Part C EIS funding expended during this reporting period (rounded to the nearest dollar):

$

2. Of the amount in Item 13a, how much is from the Minority AIDS Initiative (rounded to the nearest dollar):

$

14. Part D (including the Adolescent Initiative) funding

1. Total amount of Part D funding expended during this reporting period (rounded to the nearest dollar):

$

2. Of the amount in Item 14a, how much is from the Minority AIDS Initiative (rounded to the nearest dollar):

$

15. Amount of Part A, B, C, or D Ryan White HIV/AIDS Program funds expended on oral health care during this reporting period (rounded to the nearest dollar):

$

16. During this reporting period, did you provide the grantee with support in . . . ? (See instructions for definitions; Check “Yes” or “No” for each service.)

1. Planning or evaluation  Yes  No

2. Administrative or technical support  Yes  No

3. Fiscal intermediary services  Yes  No

4. Technical assistance  Yes  No

5. Capacity development  Yes  No

6. Quality management  Yes  No

• Check this box if the services listed in Item 16 were the only services you provided using Ryan White HIV/AIDS Program funds. If so, STOP HERE and do not complete the remainder of this form.

NOTE: Those who provided a direct service other than those listed in Item 16 should continue with Item 17a.

NOTE: Third party administrators who processed fee-for-service reimbursements to providers of eligible services should continue with Item 17a.

17. a. Did you administer an AIDS Drug Assistance Program (ADAP) or Local AIDS Pharmaceutical Assistance (APA) program that provides HIV/AIDS medication to clients during this reporting period?

• Yes

• No (Skip to Item 18.)

2. If “Yes” to Item 17a, type of program administered:

• State ADAP

• Local APA program

If the ONLY type of program you administered was a State ADAP, and you offered no other services under the Ryan White HIV/AIDS Program during this reporting period, STOP HERE. You are finished with this form. If you offered a Local APA , then you must continue to complete this form.

18. Did you provide a Health Insurance Program (HIP) during this reporting period? (Do not include health insurance funded under ADAP as a part of HIP.)

• Yes, and this was the only service your agency provided with Ryan White HIV/AIDS Program funding during this reporting period. (Skip to Section 7.)

• Yes, and your agency provided other services with Ryan White HIV/AIDS Program funding during this reporting period.

• No

19. Indicate which of the following populations were especially targeted for outreach or services during this reporting period. (Check box for each group targeted.)

• Migrant or seasonal workers

• Rural populations other than migrant or seasonal workers

• Women

• Children

• Racial/ethnic minorities/communities of color

• Homeless

• Gay, lesbian, and bisexual youth

• Gay, lesbian, and bisexual adults

• Incarcerated individuals

• All adolescents

• Runaway or street youth

• Injection drug users

• Non-injection drug users

• Parolees

• Other (specify: )

20. Which of the following categories describes your agency? (Check all that apply.)

• An agency in which racial/ethnic minority group members make up more than 50% of the agency’s board members

• Racial/ethnic minority group members make up more than 50% of the agency’s professional staff members in HIV direct services

• Solo or group private health care practice in which more than 50% of the clinicians are racial/ethnic minority group members

• Other “traditional” provider that has historically served racial/ethnic minority clients but does not meet any of the criteria above

• Other type of agency or facility

21. Total paid staff, in FTEs, funded by any Part of the Ryan White HIV/AIDS Program:

Paid staff FTEs

22. Total volunteer staff, in FTEs, dedicated to HIV care:

Volunteer staff FTEs

Section 2. Client Information

Service providers funded under all Parts should complete this section. Clients reported in this section should include your HIV-infected, HIV-indeterminate, and HIV-affected population, whether receiving core medical services or support services. Affected clients include those who are HIV-negative as well as those with unknown HIV status. An affected client must be linked to a client infected with HIV/AIDS. An indeterminate client is a child under the age of 2, born to a mother who is HIV-infected, and whose status is not yet definite.

Remember your reporting scope. If you chose reporting scope “01” in Item 6, provide information on all clients who received a service eligible for Ryan White HIV/AIDS Program funding. If you chose reporting scope “02” in Item 6, include only clients who received services funded by Part A, B, C, and/or D.

23. Total number of unduplicated clients:

HIV-positive

HIV-indeterminate (under 2 years)

HIV-negative (affected)

Unknown/unreported (affected)

Total

24. Total number of new clients:

HIV-positive

HIV-indeterminate (under 2 years)

HIV-negative (affected)

Unknown/unreported (affected)

Total

25. Gender:

Number of clients:	HIV-positive/ indeterminate		HIV-affected
Male
Female
Transgender
Unknown/unreported
Total

26. Age (at the end of reporting period):

    Number of clients:	HIV-positive/ indeterminate		HIV-affected
    Under 2 years
    2–12 years
    13–24 years
    25–44 years
    45–64 years
    65 years or older
    Unknown/unreported
    Total

27. Race and ethnicity:

a. Hispanic:

Number of clients:	HIV-positive/ indeterminate		HIV-affected
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
More than one race
Not reported
Total

b. Non-Hispanic:

Number of clients:	HIV-positive/ indeterminate			HIV-affected
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
More than one race
Not reported
Total

28. Household income (at the end of reporting period):

Number of clients:	HIV-positive/ indeterminate		HIV-affected
Equal to or below the Federal poverty level
101–200% of the Federal poverty level
201–300% of the Federal poverty level
> 300% of the Federal poverty level
Unknown/unreported
Total

29. Housing/living arrangements (at the end of reporting period):

Number of clients:	HIV-positive/ indeterminate		HIV-affected
Permanently housed
Non-permanently housed
Institution
Other
Unknown/unreported
Total

30. Medical insurance (at the end of reporting period):

    Number of clients:	HIV-positive/ indeterminate		HIV-affected
    Private
    Medicare
    Medicaid
    Other public
    No insurance
    Other
    Unknown/unreported
    Total

31. HIV/AIDS status (at the end of reporting period):

Number of clients:	HIV-positive/ indeterminate		HIV-affected
HIV-positive, not AIDS
HIV-positive, AIDS status unknown
CDC-defined AIDS
HIV-indeterminate (under 2 years)
HIV-negative (affected clients only)
Unknown/unreported (affected clients only)
Total

32. Clients’ vital/enrollment status (at the end of reporting period):

Number of clients:	HIV-positive/ indeterminate		HIV-affected
Active client, new to program
Active client, continuing in program
Deceased
Inactive
Unknown/unreported
Total

Section 3.Service Information

Service providers funded under all Parts should complete this section. If you offered a particular service, check the box in column 2 and list the number of clients and the total number of visits within each service category. If you offered a particular service but do not know the number of clients or visits during the reporting period, check the unknown box. Include HIV-indeterminate clients in the HIV+ column. Core services for affected clients are not eligible for Ryan White HIV/AIDS Program funding.

33. Services offered, number of clients served, and total number of visits during this reporting period:

	1	2	3a		3b	4a		4b
	Service Categories	Check if service was offered	Total # of unduplicated clients		Check if # of clients unknown	Total # of visits during reporting period		Check if # of visits unknown
			HIV+	Affected		HIV+	Affected
	CORE SERVICES
a.	Outpatient/ambulatory medical care
b.	Local AIDS Pharmaceutical Assistance
c.	Oral health care
d.	Early intervention services (Parts A and B)
e.	Health Insurance Premium & Cost Sharing Assistance
f.	Home health care
g.	Home and community-based health services
h.	Hospice services
i.	Mental health services
j.	Medical nutrition therapy
k.	Medical case management (including treatment adherence)
l.	Substance abuse services–outpatient
	SUPPORT SERVICES
m.	Case management (non-medical)
n.	Child care services
o.	Pediatric development assessment/early intervention services
p.	Emergency financial assistance
q.	Food bank/home-delivered meals
r.	Health education/risk reduction
s.	Housing services
t.	Legal services
u.	Linguistics services
v.	Medical transportation services
w.	Outreach services
x.	Permanency planning
y.	Psychosocial support services
z.	Referral for health care/supportive services
aa.	Rehabilitation services
ab.	Respite care
ac.	Substance abuse services-residential
ad.	Treatment adherence counseling

Section 4.HIV Counseling and Testing

Parts A, B, C, and D grantees/service providers that selected the eligible reporting scope “01” in Item 6, and provided HIV counseling and testing during this reporting period, must report on all Items in Section 4. Those who selected the funded reporting scope “02” in Item 6, and provided HIV counseling and testing, but did not use Ryan White HIV/AIDS Program funds for testing during this reporting period, should respond “Yes” to Item 34, “No” to Item 35, and then skip to Section 5.

Report the number of individuals who received HIV counseling and testing during the reporting period. This number should include ALL individuals who received HIV counseling and testing in your program, whether or not they were reported as clients in Section 2. This is the only section of the Ryan White HIV/AIDS Program Data Report where individuals who are not considered clients may be reported.

NOTE: HIV counseling and testing are funded as components of Early Intervention Services for Parts A and B. HIV counseling and testing are required components of a Part C program. Part D funds may be used to support these services.

34. a. Were HIV counseling and testing provided as part of your program during this reporting period?

 Yes (Continue.)

 No (Skip to Section 5.)

NOTE: If HIV counseling and testing were the ONLY services you provided, complete only Sections 1 and 4.

2. Indicate the total number of infants tested during this reporting period.

___________ Number of infants tested

35. Were Ryan White HIV/AIDS Program funds used to support HIV counseling and testing services during this reporting period?

 Yes (Continue.)

 No (Skip to Section 5 if you selected scope “02.”)

36. How many individuals received HIV pretest counseling during this reporting period?

Number of:

___________ Confidential

___________ Anonymous

(If answer to both categories is “0,” skip to Item 41a.)

37. How many individuals were tested for HIV during this reporting period?

Number of:

___________ Confidential

___________ Anonymous

38. Of the individuals who were tested for HIV (Item 37 above), how many had a positive test result during this reporting period?

39. Of the individuals who were tested for HIV (Item 37 above), how many received HIV-posttest counseling during this reporting period, regardless of test results?

Number of:

___________ Confidential

___________ Anonymous

40. Of the individuals who tested POSITIVE (Item 38 above), how many did NOT return for HIV-posttest counseling during this reporting period?

41. a. Did your program offer partner notification services during this reporting period?

 Yes

 No (Skip to Section 5.)

2. If “Yes” in Item 41a, how many at-risk partners were notified during this reporting period?

Section 5.Medical Information

This section should be completed by all medical service providers funded through the Ryan White HIV/AIDS Program Parts A, B, C, or D. This section should include only clients who were HIV-positive/indeterminate and had at least one outpatient/ambulatory medical care visit during the reporting period. It is expected that grantees who contract with multiple fee for service medical providers will report the medical information for all providers that do not complete a Data Report.

42. Total number of unduplicated clients with visits for outpatient/ambulatory medical care by gender:

Male

Female

Transgender

Unknown/unreported

Total

43. For all clients with visits for outpatient/ambulatory medical care (total in Item 42 above), indicate the number of clients with:

1 outpatient/ambulatory medical care visit

2 visits

3-4 visits

5 or more visits

Number for whom visit count is unknown

Total

44. Total number of clients who were HIV-positive/ indeterminate with each of the listed risk factors for HIV infection:

Clients with more than one reported mode of exposure to HIV are counted in the exposure category listed first in the hierarchy, except for males with a history of both sex with men and injection drug use. They are counted in the separate category, MSM and IDU.

Men who have sex with men (MSM)

Injection drug user (IDU)

Men who have sex with men and injection drug user (MSM and IDU)

Hemophilia/coagulation disorder

Heterosexual contact

Receipt of transfusion of blood, blood components, or tissue

Mother with/at risk for HIV infection (perinatal transmission)

Other

Undetermined/unknown/risk not reported or identified

Total

45. Number of clients (reported in Item 42) who received HIV-outpatient/ambulatory medical care from your agency for the first time during this reporting period:

New clients

46. Of the clients who were new to HIV-outpatient/ambulatory medical care (Item 45 above), indicate how many received the following tests at least once during this reporting period:

CD4 Count

Viral Load

47. Latent tuberculosis (TB) testing:

1. Number of clients for whom a latent TB test (skin or blood) was indicated during this reporting period:

2. Of those clients reported in Item 47a above, list the number of clients who received a TB test (skin or blood) during this reporting period:

2. Of those clients reported in Item 47b above, how many were:

Negative

Positive

Indeterminate

Unknown (did not return for reading; lost to follow-up)

2. Of those clients who tested positive in Item 47c above, how many received:

Treatment of Latent Tuberculosis Infection (LTBI)

Treatment for active TB disease

Unknown/lost to follow-up

2. Of those clients who started treatment (in Item 47d), how many:

Completed treatment of LTBI

Completed treatment for active TB disease

Are currently undergoing treatment for either LTBI or active TB disease

Are unknown, lost to follow-up, or did not complete treatment

48. Number of clients who received each of the following at any time during this reporting period:

Screening/testing for syphilis

Treatment for syphilis

Screening/testing for any sexually transmitted infection (STI) other than syphilis

Treatment for an STI (other than syphilis)

Screening/testing for hepatitis C

Treatment for hepatitis C

49. Number of clients who were newly diagnosed with AIDS during this reporting period (See instructions for the criteria for an AIDS diagnosis):

50. Number of HIV-positive clients known to have died during this reporting period:

51. Number of clients on the following types of antiretroviral therapies at the end of the reporting period:

None

HAART

Other (mono or dual therapy)

Unknown/unreported

Total

52. Number of women who received a pelvic exam and cervical Pap test during this reporting period:

53. Pregnancy:

1. Number of women who were HIV-positive and were pregnant during this reporting period:

2. Number of pregnant women (Item 53a above), who entered prenatal care in the:

First trimester

Second trimester

Third trimester

At time of delivery

Unknown

Total

2. Number of pregnant women (Item 53a above), who received antiretroviral medications to prevent the transmission of HIV to their children:

2. Number of infants delivered to pregnant women (Item 53a above):

2. Report the HIV status at the end of the reporting period of the infants delivered (Item 53d above):

HIV-positive, confirmed

HIV-indeterminate

HIV-negative, confirmed

54. What type of quality management program did your agency use to assess services by medical providers during this reporting period? (Check only one.)

• None

• Quality management program introduced this reporting period

• Established quality management program

• Established program with new quality standards added this reporting period

Section 6.DEmographic Tables/PART-Specific Data for Parts C and D

Section 6.1 should be completed by Part C grantees/service providers. Section 6.2 should be completed by Part D, including Adolescent Initiative, grantees/service providers. Part A and Part B grantees should skip to Section 7.

Section 6.1 Part C Information

Section 6.1 should be completed only by Part C grantees/service providers that provide primary health care services with Part C funds. Include all of your clients who are HIV-positive or HIV-indeterminate and have received at least one primary health care service during the reporting period, regardless of the funding source for that service. Primary health care services include medical, subspecialty care, dental, nutrition, mental health and substance abuse treatment, medical case management, and pharmacy services; as well as radiology, laboratory and other tests for diagnosis and treatment planning; HIV counseling and testing; and the cost of making and tracking referrals for medical care. An indeterminate client is a child under the age of 2, born to a mother who is HIV-infected, and whose status is not yet definite.

The number of clients reported in Section 6.1 should be less than or equal to the number of unduplicated HIV- positive/indeterminate clients reported in Section 2.

If the number of clients reported in Section 6.1 is equal to the number of unduplicated HIV-positive/indeterminate clients reported in Section 2, check here.  (Skip to Item 59.)

55. a. Total number of unduplicated clients during this reporting period who were:

HIV-positive

HIV-indeterminate (under 2 years)

Total

2. Number of unduplicated HIV-positive/indeterminate clients who were new clients during this reporting period

56. Gender (of HIV-positive/indeterminate clients) reported in Item 55a:

Male

Female

Transgender

Unknown/unreported

Total

57. Age (of HIV-positive/indeterminate clients) reported in Item 55a:

Under 2 years

2–12 years

13–24 years

25–44 years

45–64 years

65 years or older

Unknown/unreported

Total

58. Race and ethnicity (of HIV-positive/indeterminate clients) reported in Item 55a:

Number of clients:	Hispanic		Non-Hispanic
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
More than one race
Not reported
Total

59. Number of clients who were HIV-positive/indeterminate who received at least one primary health care service during this reporting period by ethnicity, race, gender, and age.

a. Number of HISPANIC clients.

Race	Gender	Under 2 years	2–12 years	13–24 years	25–44 years	45–64 years	65 years and older	Age unknown	Total
American Indian or Alaska Native	Male
	Female
	Transgender
	Unknown/ unreported
Asian	Male
	Female
	Transgender
	Unknown/ unreported
Black or African American	Male
	Female
	Transgender
	Unknown/ unreported
Native Hawaiian or Other Pacific Islander	Male
	Female
	Transgender
	Unknown/ unreported
White	Male
	Female
	Transgender
	Unknown/ unreported
More than one race	Male
	Female
	Transgender
	Unknown/ unreported
Not reported	Male
	Female
	Transgender
	Unknown/ unreported
Total	Male
	Female
	Transgender
	Unknown/ unreported

b. Number of NON-HISPANIC clients.

Race	Gender	Under 2 years	2–12 years	13–24 years	25–44 years	45–64 years	65 years and older	Age unknown	Total
American Indian or Alaska Native	Male
	Female
	Transgender
	Unknown/ unreported
Asian	Male
	Female
	Transgender
	Unknown/ unreported
Black or African American	Male
	Female
	Transgender
	Unknown/ unreported
Native Hawaiian or Other Pacific Islander	Male
	Female
	Transgender
	Unknown/ unreported
White	Male
	Female
	Transgender
	Unknown/ unreported
More than one race	Male
	Female
	Transgender
	Unknown/ unreported
Not reported	Male
	Female
	Transgender
	Unknown/ unreported
Total	Male
	Female
	Transgender
	Unknown/ unreported

60. Number of clients who were HIV-positive/indeterminate who received at least one primary health care service during this reporting period by ethnicity, HIV exposure category, gender, and race.

a. Number of HISPANIC clients.

HIV Exposure Category	Gender	American Indian/ Alaska Native	Asian	Black or African American	Native Hawaiian or Other Pacific Islander	White	More than one race	Not reported	Total
Men who have sex with men (MSM)	Male
	Female
	Transgender
	Unknown/ unreported
Injection drug user (IDU)	Male
	Female
	Transgender
	Unknown/ unreported
MSM and IDU	Male
	Female
	Transgender
	Unknown/ unreported
Hemophilia/ coagulation disorder	Male
	Female
	Transgender
	Unknown/ unreported
Heterosexual contact	Male
	Female
	Transgender
	Unknown/ unreported
Receipt of transfusion of blood, blood components, or tissue	Male
	Female
	Transgender
	Unknown/ unreported
Mother with/at risk for HIV infection (perinatal transmission)	Male
	Female
	Transgender
	Unknown/ unreported
Other	Male
	Female
	Transgender
	Unknown/ unreported
Unknown/ unreported	Male
	Female
	Transgender
	Unknown/ unreported
Total	Male
	Female
	Transgender
	Unknown/ unreported

b. Number of NON-HISPANIC clients.

HIV Exposure Category	Gender	American Indian/ Alaska Native	Asian	Black or African American	Native Hawaiian or Other Pacific Islander	White	More than one race	Not reported	Total
Men who have sex with men (MSM)	Male
	Female
	Transgender
	Unknown/ unreported
Injection drug user (IDU)	Male
	Female
	Transgender
	Unknown/ unreported
MSM and IDU	Male
	Female
	Transgender
	Unknown/ unreported
Hemophilia/ coagulation disorder	Male
	Female
	Transgender
	Unknown/ unreported
Heterosexual contact	Male
	Female
	Transgender
	Unknown/ unreported
Receipt of transfusion of blood, blood components, or tissue	Male
	Female
	Transgender
	Unknown/ unreported
Mother with/at risk for HIV infection (perinatal transmission)	Male
	Female
	Transgender
	Unknown/ unreported
Other	Male
	Female
	Transgender
	Unknown/ unreported
Unknown/ unreported	Male
	Female
	Transgender
	Unknown/ unreported
Total	Male
	Female
	Transgender
	Unknown/ unreported

61. Number of clients who were HIV-positive/indeterminate who received at least one primary health care service during this reporting period by HIV exposure category, gender, and age.

HIV Exposure Category	Gender	Under 2 years	2–12 years	13–24 years	25–44 years	45–64 years	65 years and older	Age unknown	Total
Men who have sex with men (MSM)	Male
	Female
	Transgender
	Unknown/ unreported
Injection drug user (IDU)	Male
	Female
	Transgender
	Unknown/ unreported
MSM and IDU	Male
	Female
	Transgender
	Unknown/ unreported
Hemophilia/ coagulation disorder	Male
	Female
	Transgender
	Unknown/ unreported
Heterosexual contact	Male
	Female
	Transgender
	Unknown/ unreported
Receipt of transfusion of blood, blood components, or tissue	Male
	Female
	Transgender
	Unknown/ unreported
Mother with/at risk for HIV infection (perinatal transmission)	Male
	Female
	Transgender
	Unknown/ unreported
Other	Male
	Female
	Transgender
	Unknown/ unreported
Unknown/ unreported	Male
	Female
	Transgender
	Unknown/ unreported
Total	Male
	Female
	Transgender
	Unknown/ unreported

62. Cost and revenue of primary health care* and other programs^† during this reporting period:

1. Total cost of providing service:

$ Primary health care

$ Other program

2. Part C grant funds expended:

$ Primary health care (excluding pharmaceuticals)

$ Other program

$ Pharmaceuticals

2. Direct collections from clients:

$ Primary health care

$ Other program

2. Reimbursements received from third party payer:

$ Primary health care

$ Other program

2. All other sources of income:

$ Primary health care

$ Other program

*Includes medical, subspecialty care, dental, nutrition, mental health and substance abuse treatment, medical case management, and pharmacy services; as well as radiology, laboratory and other tests for diagnosis and treatment planning; HIV counseling and testing; and the cost of making and tracking referrals for medical care.

†Includes non-medical case management and eligibility assistance, outreach, social work, health education, and risk reduction. If you are providing a Part C-eligible service, include it, even if it is not being funded under your grant.

63. a. Were services available through your Early Intervention Services (EIS) program provided at more than one site during this reporting period?

 Yes

 No (Skip to Item 64.)

2. If “Yes” to Item 63a, number of sites at which Early Intervention Services were provided during this reporting period:

64. Please indicate which of the following primary health care services were made available to your clients who were HIV-positive or HIV-indeterminate during this reporting period. (Choose “Yes, within the EIS program” if you offered the service directly and/or through a contractual relationship with another service provider. Choose “Yes, through referral” if it was offered by another agency with which you had no remunerative relationship but to whom you referred. Choose “No” if the service was not available.)

		Yes, within the EIS program	Yes, through referral	No
		▼	▼	▼
a.	Outpatient/ambulatory medical care	
b.	Dermatology			
c.	Dispensing of pharmaceuticals			
d.	Gastroenterology			
e.	Medical case management			
f.	Medical nutrition therapy			
g.	Mental health services			
h.	Neurology			
i.	Obstetrics/gynecology			
j.	Optometry/ophthalmology			
k.	Oral health care			
l.	Substance abuse services			
m.	Other services			

65. During this reporting period, how many unduplicated clients who were HIV-positive were referred outside the EIS program for any primary health care service that was not available within the EIS program?

Section 6.2 Part D Information

Section 6.2 should be completed only by Part D, including Adolescent Initiative, grantees/service providers. Report the Part D clients who were HIV-infected or HIV-indeterminate as well as their affected partner/family member(s). Include only those clients who received Part D services. An indeterminate client is a child under the age of 2, born to a mother who is HIV-infected, and whose status is not yet definite.

The number of clients reported in Section 6.2 should be less than or equal to the number of unduplicated clients reported in Section 2.

If the number of clients reported in Section 6.2 is equal to the number of unduplicated clients reported in Section 2, check here.  (Skip to Item 71.)

66. Total number of unduplicated clients during this reporting period who were:

HIV-positive

HIV-indeterminate (under 2 years)

HIV-negative/unknown

Total

67. Total number of NEW unduplicated clients during this reporting period who were:

HIV-positive

HIV-indeterminate (under 2 years)

HIV-negative/unknown

Total

68. Gender:

    Number of clients:	HIV-positive/ indeterminate		HIV-affected
    Male
    Female
    Transgender
    Unknown/unreported
    Total

69. Age:

Number of clients:	HIV-positive/ indeterminate		HIV-affected
Under 2 years
2–12 years
13–24 years
25–44 years
45–64 years
65 years or older
Unknown/unreported
Total

70. Race and ethnicity:

a. Hispanic:

Number of clients:	HIV-positive/ indeterminate		HIV-affected
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
More than one race
Not reported
Total

b. Non-Hispanic:

Number of clients:	HIV-positive/ indeterminate			HIV-affected
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
More than one race
Not reported
Total

71. Number of clients during this reporting period by gender, HIV status, and age.

Gender	HIV Status	Under 2 years	2–12 years	13–24 years	25–44 years	45–64 years	65 years and older	Age unknown	Total
Male	HIV+/indeterminate
	HIV-/unknown
Female	HIV+/indeterminate
	HIV-/unknown
Transgender	HIV+/indeterminate
	HIV-/unknown
Unknown/ unreported	HIV+/indeterminate
	HIV-/unknown
Total	HIV+/indeterminate
	HIV-/unknown

72. Number of clients during this reporting period by race, ethnicity, HIV status, and age.

a. Number of HISPANIC clients.

Race	HIV Status	Under 2 years	2–12 years	13–24 years	25–44 years	45–64 years	65 years and older	Age unknown	Total
American Indian or Alaska Native	HIV+/indeterminate
	HIV-/unknown
Asian	HIV+/indeterminate
	HIV-/unknown
Black or African American	HIV+/indeterminate
	HIV-/unknown
Native Hawaiian or Other Pacific Islander	HIV+/indeterminate
	HIV-/unknown
White	HIV+/indeterminate
	HIV-/unknown
More than one race	HIV+/indeterminate
	HIV-/unknown
Not reported	HIV+/indeterminate
	HIV-/unknown
Total	HIV+/indeterminate
	HIV-/unknown

b. Number of NON-HISPANIC clients.

Race	HIV Status	Under 2 years	2–12 years	13–24 years	25–44 years	45–64 years	65 years and older	Age unknown	Total
American Indian or Alaska Native	HIV+/indeterminate
	HIV-/unknown
Asian	HIV+/indeterminate
	HIV-/unknown
Black or African American	HIV+/indeterminate
	HIV-/unknown
Native Hawaiian or Other Pacific Islander	HIV+/indeterminate
	HIV-/unknown
White	HIV+/indeterminate
	HIV-/unknown
More than one race	HIV+/indeterminate
	HIV-/unknown
Not reported	HIV+/indeterminate
	HIV-/unknown
Total	HIV+/indeterminate
	HIV-/unknown

73. Number of clients who were HIV-POSITIVE OR INDETERMINATE during this reporting period by HIV exposure category and age.

HIV Exposure Category	Under 2 years	2–12 years	13–24 years	25–44 years	45–64 years	65 years and older	Age unknown	Total
Men who have sex with men (MSM)
Injection drug user (IDU)
MSM and IDU
Hemophilia/coagulation disorder
Heterosexual contact
Receipt of transfusion of blood, blood components, or tissue
Mother with/at risk for HIV infection (perinatal transmission)
Other
Undetermined/unknown
Total

STOP HERE IF YOU DO NOT PROVIDE HEALTH INSURANCE PROGRAM (HIP) SERVICES
TO YOUR CLIENTS!

Section 7.HEALTH INSURANCE Program (HIP) Information

This section should be completed by the state agency and other entities that used Ryan White HIV/AIDS Program funds, except funds from ADAP, to pay for or supplement a client’s health insurance. This section should not be completed by grantees that provide funding to another HIP, or by service providers that only provide vouchers for health insurance. Data on Health Insurance Programs funded through ADAP should be reported in the ADAP Quarterly Reports.

A Health Insurance Program is a program authorized and primarily funded under Part A or Part B of the Ryan White HIV/AIDS Program that makes premium payments, co-payments, deductibles, or risk pool payments on behalf of a client to maintain his/her health insurance coverage.

1. Total number of UNDUPLICATED clients in this reporting period:

2. Total number of NEW clients served in this reporting period:

3. Gender:

Number of clients:

Male

Female

Transgender

Unknown/unreported

Total

4. Age (at the end of reporting period):

Number of clients:

Under 2 years

2–12 years

13–24 years

25–44 years

45–64 years

65 years or older

Unknown/unreported

Total

5. Race and ethnicity:

   Number of clients:	Hispanic		Non-Hispanic
   American Indian or Alaska Native
   Asian
   Black or African American
   Native Hawaiian or Other Pacific Islander
   White
   More than one race
   Not reported
   Total

6. Annual expenditures for HIP:

   Source	Total cost	Undup-licated clients	Total client-months
   High-risk insurance pool
   Premiums	$ _, _ _ _, _ _ _	_ _ _ _	_ _ _, _ _ _
   Deductibles	$ _, _ _ _, _ _ _	_ _ _ _	_ _ _, _ _ _
   Co-payments	$ _, _ _ _, _ _ _	_ _ _ _	_ _ _, _ _ _
   Medicare supplement
   Premiums	$ _, _ _ _, _ _ _	_ _ _ _	_ _ _, _ _ _
   Deductibles	$ _, _ _ _, _ _ _	_ _ _ _	_ _ _, _ _ _
   Co-payments	$ _, _ _ _, _ _ _	_ _ _ _	_ _ _, _ _ _
   Other health insurance
   Premiums	$ _, _ _ _, _ _ _	_ _ _ _	_ _ _, _ _ _
   Deductibles	$ _, _ _ _, _ _ _	_ _ _ _	_ _ _, _ _ _
   Co-payments	$ _, _ _ _, _ _ _	_ _ _ _	_ _ _, _ _ _
   TOTAL HEALTH INSURANCE EXPENDITURES
   Premiums	$ _, _ _ _, _ _ _	_ _ _ _	_ _ _, _ _ _
   Deductibles	$ _, _ _ _, _ _ _	_ _ _ _	_ _ _, _ _ _
   Co-payments	$ _, _ _ _, _ _ _	_ _ _ _	_ _ _, _ _ _

7. Total expenditures: (Include Item 79 above, “Total Health Insurance Expenditures” plus any other administrative costs.)

$__ __ , __ __ __, __ __ __

8. Annual HIP funding by Ryan White HIV/AIDS Program sources:

   Funding source	Funding expended
   Total Part A funds	$ _ _, _ _ _, _ _ _
   EMA/TGA #1 __ __ __ __	$ _ _, _ _ _, _ _ _
   EMA/TGA #2 __ __ __ __	$ _ _, _ _ _, _ _ _
   EMA/TGA #3 __ __ __ __	$ _ _, _ _ _, _ _ _
   EMA/TGA #4 __ __ __ __	$ _ _, _ _ _, _ _ _
   EMA/TGA #5 __ __ __ __	$ _ _, _ _ _, _ _ _
   EMA/TGA #6 __ __ __ __	$ _ _, _ _ _, _ _ _
   EMA/TGA #7 __ __ __ __	$ _ _, _ _ _, _ _ _
   EMA/TGA #8 __ __ __ __	$ _ _, _ _ _, _ _ _
   EMA/TGA #9 __ __ __ __	$ _ _, _ _ _, _ _ _
   EMA/TGA #10 __ __ __ __	$ _ _, _ _ _, _ _ _
   Total Part B funds	$ _ _, _ _ _, _ _ _
   Total Part C funds	$ _ _, _ _ _, _ _ _
   Other Ryan White HIV/AIDS Program funding	$ _ _, _ _ _, _ _ _

9. Annual HIP funding by other sources:

Funding source	Funding received
Federal Section 330	$ _ _, _ _ _, _ _ _
Other Federal funding	$ _ _, _ _ _, _ _ _
State/Local	$ _ _, _ _ _, _ _ _
Client payments	$ _ _, _ _ _, _ _ _
All other sources not included above	$ _ _, _ _ _, _ _ _

END OF REPORT

Instructions for CARE Act Data Report 0