Project Clinic Characteristics Form

Attachment 3 Clinic Project ID: __________

Form Approved

OMB No: 0920-XXXX

Exp. Date: XX/XX/XXXX

Project Clinic Characteristics Form

Public reporting burden of this collection of information is estimated to average 30 minutes 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)

Project Clinic Characteristics form

Please provide the following information for the 12 month calendar year

Location	City/Town: _____________					State: _____________
Type of clinic (check all that apply):	□ public					□ private
	□ primary care clinic					□ ID or HIV specialty clinic
For public clinic (check all that apply):	□ Federally Qualified Health Center			□ Community Health Center				□ Ryan White clinic
	□ other __________
For private clinic (check all that apply):	□ managed care clinic			□ academic medical center clinic				□ non-academic medical center clinic
	□ retail clinic			□ other __________
Location:	□ urban			□ suburban				□ rural
Year (that the following information covers):	□ 2012		□ 2013		□ 2014		□ 2015		□ 2016
Total number of patients at the clinic? _______
Total number of patients by sex:	Male ________					Female _________
Total number of patients by race:
American Indian/Alaska Native ________		Asian ________				Black/African American ________
Native Hawaiian/Pacific Islander ________		White _______				Unknown ________
Bi-racial ________		Other: ­­­­_______
Total number of patients by ethnicity:
Hispanic/Latino ________	Not Hispanic/Latino _______					Unknown ________
Total number of patients at the clinic that are HIV positive: _________
Number of insured HIV positive patients: _________			Number of insured non-HIV positive patients: _________
Of the insured HIV positive patients, the number of insured patients by insurance type:
Private insurance _________	Medicaid _________					Medicare __________
Tricare _________	Other _________					Unknown __________
Number of total clinic visits (for all patients): __________
Number of individual patient visits for HIV-positive patients: __________
Number of individual patient visits for HIV positive patients that were kept: __________
Number of individual patient visits for non-HIV-positive patients: __________
Number of individual patient visits for non-HIV positive patients that were kept: __________
Does the clinic have access to an on-site pharmacy? □ yes □ no
Does the clinic have 340b status? □ yes □ no

	%
Percentage of HIV patients that are on ART
Percentage of HIV patients that are virally suppressed
Percentage of HIV patients who have missed scheduled appointments in the passed 6 months

How many Full Time Equivalent (FTE)* providers (clinical or other provider types) did the clinic have in calendar year? ______
Type of provider	Number of FTE provider(s)
Physician^
Physician Assistant
Nurse Practitioner
Pharmacist
Registered Nurse, Licensed Nurse
Dietician
Case Manager
Social Worker
Substance Abuse Counselor
Laboratory staff
Other type:

*FTE is the ratio of the total number of paid hours during a period divided by the number of working hours in that period. An FTE of 1.0 means that the person is equivalent to a full-time worker, while an FTE of 0.5 indicates that the worker is only half-time

^Physicians in residency training should not be included

Average number of patients seen, per day, by 1 FTE staff in calendar year:

Physician(s) ________

Physician Assistant(s) ________

Nurse Practitioner(s) ________

Pharmacist(s) ________

Registered Nurse(s), Licensed Nurse(s) ________

Case Manager(s) ________

Social Worker(s) ________

Substance Abuse Counselor(s) ________

Other(s)

type: ________

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