Project Pharmacy Characteristics Form

Integrating Community Pharmacists and Clinical Sites for Patient-Centered HIV Care

Att 4_Project pharmacy characterisitics form

Project Pharmacy Characteristics Form

OMB: 0920-1019

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Attachment 4 Pharmacy Project ID: __________



Form Approved

OMB No: 0920-XXXX

Exp. Date: XX/XX/XXXX







Project Pharmacy 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 Pharmacy Characteristics form

Please provide the following information for the 12 month calendar year

Location:

City/Town: ____________

State: _____________

Type of pharmacy:

□ Traditional retail

□ Specialty-trained retail

Year (that the following information covers):

□ 2012

□ 2013

□ 2014

□ 2015

□ 2016

Number of years and months the pharmacy has been an HIV Center of Excellence:


Years: __________ Months: __________

Number of individual HIV clients for whom prescriptions were filled : __________

Number of individual non-HIV clients for whom prescriptions were filled : __________

Average number of individual HIV clients served per month: __________

Average number of individual non-HIV clients served per month: __________

Average number of HIV prescriptions sold per day: __________

Average number of non-HIV prescriptions sold per day: __________

Average number of individual HIV clients served per day: __________

Average number of individual non-HIV clients served per day: __________

Percentage of total revenue from HIV-related therapy: __________

Number of insured patients: _________

Number of non-insured patients: _________

Of the insured patients, the number of insured patients by insurance type:

Private insurance _________

Medicaid _________

Medicare __________

ADAP _________

Other _________

Does pharmacy offer the following services? (check all that apply)

□ immunizations

□ smoking cessation counseling

□ diabetes management

□ health screening tests (e.g. glucose test, lipid tests, HIV tests)


How many full time equivalent (FTE)* pharmacy staff did the pharmacy have? ______________

Type of provider

Number of FTE provider(s)

Pharmacist


Pharmacy Technician


*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

File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorByrd, Kathy K. (CDC/OID/NCHHSTP)
File Modified0000-00-00
File Created2021-01-25

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