Program-level data

Form Approved
OMB No. 0920-New
Expiration Date 00/00/00

Hepatitis Testing and Linkage to Care (HEPTLC) Monitoring & Evaluation System
Programmatic Reporting Template
Attachment 5

Public reporting burden of this collection of information is estimated to average 1.5 hours per response, including the time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. 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. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this
burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; Attn: OMB-PRA (0920-New)

age range among persons tested:

race/ethnicity among
persons tested:

among persons tested HBV postitive:

Among all participants tested, including SRP and non-SRP
prevalence=
# tested

# confirmed pos

# confirmed pos
# tested

# nwly dx (not
SRP)

risk
obtained

previous
tested

SRP

tested for
HBV core
antibody

HBV core
antibody
positive

tested for
HBV
surface
antigen

HBV
surface
antigen
Positive

of persons
tested, % 18-24 25-34 35-44 45-54 55-64
Pos

≥65

AA

W

H/L Asn Oth

of persons
revived test
positive
result

of persons
received
post-test
counseling

of persons
linked to
care

of persons
reported to
surveillance

YTD totals=
Test result data are shown in aggregate.
Data reflect only date between 00/00/2013 to 00/00/2013 as some of test
results have not yet returned

Avg per event=
Averages are rounded down to the nearest whole number.

age range among persons tested:

Event #

Date

attendee screened

screened
eligible
persons

consented to
testing

risk
obtained

previous
tested

SRP

tested for
HBV core
antibody

HBV core
antibody
positive

tested for
HBV
surface
antigen

HBV
surface
antigen
Positive

of persons
tested, % 18-24 25-34 35-44 45-54 55-64
Pos

≥65

race/ethnicity among
persons tested:

AA

W

H/L Asn Oth

among persons tested HBV postitive:
of persons
revived test
positive
result

of persons
received
post-test
counseling

of persons
linked to
care

of persons
reported to
surveillance

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27

Note: Please do not change red or yellow values (automatically generated by formula.) Please only change green cell values. Thank you.

age range among persons tested:

race/ethnicity among
persons tested:

among persons tested HCV RNA postitive:

Among all participants tested, including SRP and non-SRP
prevalence=
# tested

# confirmed pos

# confirmed pos
# tested

# nwly dx (not
SRP)

risk
obtained

previous
tested

SRP

tested for
HCV Ab

HCV Ab
reactive

tested for
HCV RNA

RNA
Positive

of
persons
18-24 25-34 35-44 45-54 55-64
tested, %
RNA Pos

≥65

AA

W

H/L Asn Oth

of persons
received
HCV RNA
Result

of persons
received
post-test
counseling

of persons
linked to
care

of persons
reported to
surveillance

YTD totals=
Test result data are shown in aggregate.
Data reflect only date between 00/00/2013 to 00/00/2013 as some of test
results have not yet returned

Avg per event=
Averages are rounded down to the nearest whole number.

age range among persons tested:

Event #

Date

attendee screened

screened
eligible
persons

consented to
testing

risk
obtained

previous
tested

SRP

tested for
HCV Ab

HCV Ab
reactive

tested for
HCV RNA

RNA
Positive

of
persons
18-24 25-34 35-44 45-54 55-64
tested, %
RNA Pos

≥65

race/ethnicity among
persons tested:

AA

W

H/L Asn Oth

among persons tested HCV RNA postitive:
of persons
received
HCV RNA
Result

of persons
received
post-test
counseling

of persons
linked to
care

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27

Note: Please do not change red or yellow values (automatically generated by formula.) Please only change green cell values. Thank you.

of persons
reported to
surveillance

Among all participants tested, including SRP and nonSRP

# tested

# confirmed
pos

prevalence=
# confirmed pos
# tested

race/ethnicity among
persons tested:

age range among persons tested:

# nwly dx (not
SRP)

risk
obtained

previous
tested

SRP

tested for HCV Ab
HCV Ab reactive

tested for
of persons
RNA
HCV
tested, % 18-24
Positive
RNA
RNA Pos

25-34

35-44

45-54

55-64

≥65

AA

W

H/L

Asn Oth

among persons tested HCV RNA POS

of persons
received
HCV RNA
Result

of persons
received
post-test
counseling

Among persons newly identified with HCV

of persons
of persons
quantitiativ
revieved
HCV RNA of persons
reported to
e HCV
evaluation at
Genotype begin ART
surveillance
RNA tested
ECHO

YTD totals=
Test result data are shown in aggregate.
Data reflect only date between 00/00/2013 to 00/00/2013 as
some of test results have not yet returned

Avg per event=
Averages are rounded down to the nearest whole number.

race/ethnicity among
persons tested:

age range among persons tested:

Event #

Date

attendee
screened

screened
eligible
persons

consented to testing

risk
obtained

previous
tested

SRP

tested for HCV Ab
HCV Ab reactive

tested for
of persons
RNA
HCV
tested, % 18-24
Positive
RNA
RNA Pos

25-34

35-44

45-54

55-64

≥65

AA

W

H/L

Asn Oth

among persons tested HCV RNA POS

of persons
received
HCV RNA
Result

of persons
received
post-test
counseling

Among persons newly identified with HCV

of persons
of persons
quantitiativ
revieved
HCV RNA of persons
reported to
e HCV
evaluation at
Genotype begin ART
surveillance
RNA tested
ECHO

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27

Note: Please do not change red or yellow values (automatically generated by formula.) Please only change green cell values. Thank you.