Project Pharmacy Characteristics Form

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