Form Progress Report Progress Report Progress Report

OMB No. 0930-####
Expiration Date: ##/##/####

PROGRESS REPORT: HIV GRANTEES
___ Quarterly ___ Biannual

FOA (RFA)#: ______________ Cohort: ______________ Multi-year funded: ___

Reporting Period: _____________ to ____________ Grant Year: ___ No-cost ext.: ___, # months: ___ Grantee Federal Identification #: TI ______________
Date: _______________ Project Name: _________________________________________ Grantee Name: ____________________________________
Completed by: ______________________ Title: ______________________ Telephone: ________________ CSAT Project Officer: ___________________

I. Key Staff Personnel
Key Staff

Name

Address

Email

Telephone

Project
Director
Project
Evaluator
Other:

II. Changes in Staffing Personnel (this reporting period)
A.

Staff Updates – Please complete the below table with any staff changes
Note: Project Director, Evaluator, and Program Manager/Coordinator (e.g., Clinical Supervisor) require prior CSAT approval

Name (for new hires)

Position/Title

Email

Telephone

Name (for changed roles)

Position/Title (old position)

Position/Title (new position)

Old position vacant? If so, why

B.

Other Staff Matters – Fully staffed? ___Yes ___No

Date Hired

if No, please describe staffing challenges (e.g., recruitment, retention)

III. Knowledge-building Activity (this reporting period)
Name

Position

Training Activity

Licensing
Yes
No

Technical Assistance (TA)
request/need

IV. Project Information (this reporting period)
A.

Annual Target and Goal(s)

Any change to annual targets and/or goals require prior CSAT approval

1.

Intake _____

What are your Annual Targets?

Follow-up _____

Current / Existing Goals

Approved By (SAMHSA official)

New Goals

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SAMHSA / CSAT HIV PROGRAM(S)

Revised: 10/16/2015

PROGRESS REPORT: HIV GRANTEES
2. Please explain any changes in your annual targets and/or goals, if applicable.

B.

Financial Data

Federal Funds Authorized (Annual)
Forecasted Cash Needs (Budgeted)

Q1

Q2

1st half

Q3

Q4

2nd half

TOTAL

Federal Share Spent (Expended)
a.

Substance Use Disorder (SUD) Services
SUD Treatment
Recovery Support
Other federal funding:
Other state funding:
Funding from other sources:

b.

HIV Services
Other federal funding:
Other state funding:
Funding from other sources:

c.

Hepatitis Services
Other federal funding:
Other state funding:
Funding from other sources:

d.

Contract Services

Obligated Funds
Unliquidated obligation (ULO) Funds
Unobligated (UO) Funds
Carryover Funds

C.

Care Coordination (Linkages & Referral Services)
List all organizations to which clients were referred to by your organization for additional services

Organization
(Referred To)

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Location

Referred Services (Type)

SAMHSA / CSAT HIV PROGRAM(S)

#
Referrals

Outcome of Referral(s)

MOU /
MOA

Revised: 10/16/2015

PROGRESS REPORT: HIV GRANTEES
Organization
(Referred To)

Location

Referred Services (Type)

#
Referrals

Outcome of Referral(s)

MOU /
MOA

#
Referrals

Outcome of Referral(s)

MOU /
MOA

List all organizations which referred clients to your agency (if applicable)
Organization (Referred
From)

D.

Referral Source
(e.g. Hospital)

Referred Services (Type)

Client Information
1.

Substance Use Disorder (SUD) Reporting
Q1

Q2

1st half

Q3

Q4

2nd half

TOTAL

# clients served
# intakes/admissions planned (your targets)
# intake/admissions completed
# clients completed assessment but received no treatment
# clients completed six (6) month follow-up assessment
# clients discharged prior to program completion*
# clients successfully completed treatment/program
* clients who left the program for any reason without completing their treatment plan

2.

Substance Use Disorder (SUD) / Co-occurring Disorder (COD) Treatment Reporting
SUD

Target
Population
Minority
Women

Minority
Men

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Screening tool
used

#
screened

#
referred

COD
Services provided

Screening tool
used

#
screened

#
referred

Services provided

Individual / Group Counseling

Individual / Group Counseling

Treatment

Medication

Treatment

Medication

Peer Services

Recovery
Services

Peer Services

Recovery
Services

Individual / Group Counseling

Individual / Group Counseling

Treatment

Medication

Treatment

Medication

Peer Services

Recovery
Services

Peer Services

Recovery
Services

SAMHSA / CSAT HIV PROGRAM(S)

Revised: 10/16/2015

PROGRESS REPORT: HIV GRANTEES
SUD
Target
Population
Heterosexual

Screening tool
used

#
screened

#
referred

Transgender

Bisexual

Lesbian

MSM

YMSM

Screening tool
used

#
screened

#
referred

Services provided

Individual / Group Counseling

Individual / Group Counseling

Treatment

Medication

Treatment

Medication

Peer Services

Recovery
Services

Peer Services

Recovery
Services

Individual / Group Counseling

Individual / Group Counseling

Treatment

Medication

Treatment

Medication

Peer Services

Recovery
Services

Peer Services

Recovery
Services

Individual / Group Counseling

Individual / Group Counseling

Treatment

Medication

Treatment

Medication

Peer Services

Recovery
Services

Peer Services

Recovery
Services

Individual / Group Counseling

Individual / Group Counseling

Treatment

Medication

Treatment

Medication

Peer Services

Recovery
Services

Peer Services

Recovery
Services

Individual / Group Counseling

Individual / Group Counseling

Treatment

Medication

Treatment

Medication

Peer Services

Recovery
Services

Peer Services

Recovery
Services

Individual / Group Counseling

Individual / Group Counseling

Treatment

Medication

Treatment

Medication

Peer Services

Recovery
Services

Peer Services

Recovery
Services

a.

Please enter the number (#) of Screening, Brief Intervention, and Referral to Treatment (SBIRT) conducted: _____

b.

Please list and/or update currently used evidence-based interventions / practices (EBIs / EBPs)

EBIs / EBPs

3.

COD
Services provided

SUD

COD

HIV

Hepatitis

EBIs / EBPs

SUD

COD

HIV

Hepatitis

HIV Testing Reporting
Q1

Q2

1st half

Q3

Q4

2nd half

TOTAL

HIV Testing
# staff trained on HIV testing
# HIV test kits purchased
# HIV tests planned
# HIV tests completed

HIV Positivity
# positive test results
# negative test results
# tests conducted solely to verify HIV-positive status
# tests with missing or invalid values

HIV Knowledge-status
# HIV-positive clients knowing their HIV status in 12 month period
# HIV-positive tests in 12 month period

Late HIV Diagnosis
# clients diagnosed with Stage 3 HIV infection (AIDS) within 3 months of
diagnosis of HIV infection in 12 month period
# clients with an HIV diagnosis in 12 month period

Linkage to HIV Medical Care
# clients who attended a HIV care visit within 3 months of diagnosis
# clients with an HIV diagnosis in 12 month period

Retention in HIV Medical Care
# clients with HIV diagnosis and had at least one HIV medical care visit in
each 6 month period (of 24 month period)
# clients who attended at least one HIV medical care visit in the first 6 month
period (of 24 month period)
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SAMHSA / CSAT HIV PROGRAM(S)

Revised: 10/16/2015

PROGRESS REPORT: HIV GRANTEES
Antiretroviral Therapy (ART)

(if applicable)

# clients prescribed ART in 12 month period
# clients with HIV diagnosis and had at least one HIV medical care visit in 12
month period

Viral Load Suppression

(if applicable)

# clients who have maintained a viral load <200 copies/mL at last test in 12
month period
# clients with HIV diagnosis and had at least one HIV medical care visit in 12
month period

Housing Status
# clients with an HIV diagnosis who were homeless or unstably housed in 12
month period
# clients with HIV diagnosis receiving HIV services in last 12 months

4.

Hepatitis Testing Reporting: (IF APPLICABLE)
Q1

Q2

1st half

Q3

2nd half

Q4

TOTAL

Hepatitis Testing
# staff trained on Hepatitis testing
# HBV test kits purchased
# HBV tests planned
# HBV tests completed
# HCV test kits purchased
# HCV tests planned
# HCV tests completed

Hepatitis B (HBV)
# Positives
# Negatives
# HBV tests with missing or invalid values

Hepatitis C (HCV)
# Positives
# Negatives
# HCV tests with missing or invalid values

Referral/Linkage to Care
# referrals issued for Hepatitis testing at your facility
# referrals issued for Hepatitis testing outside of your facility
# referrals issued for follow up (confirmatory) testing
# referrals issued for treatment, post-confirmatory testing
# clients who completed referral to Hepatitis medical care

Retention in Care
# clients attending routine Hepatitis medical care within 3 months of
diagnosis
# clients who attended at least one Hepatitis medical care visit in the last 6
months, if not receiving routine Hepatitis care

Hepatitis Treatment
# clients receiving HBV treatment
# clients receiving HCV treatment

Immunization Efforts
# clients vaccinated for HAV
# clients vaccinated for HBV
# clients vaccinated for HAV and HBV

5.

Outreach & Engagement Reporting
a. Please enter the # of individuals contacted during outreach (educational, pre-counseling, not enrolled in treatment)
Q1

Q2

1st half

Q3

Q4

2nd half

TOTAL

Comprehensive (Comp.) **
SUD/COD/Trauma
SUD/COD
HIV
Hepatitis
Trauma
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SAMHSA / CSAT HIV PROGRAM(S)

Revised: 10/16/2015

PROGRESS REPORT: HIV GRANTEES
** An inclusive event that incorporates SUD, COD, Trauma, HIV, and/or Hepatitis (if, applicable) together

Please enter the # of visits to the following venues during this reporting period

Other:

Greek (e.g., frat)
House

College Campus

Cyberspace

Social Media

Program
Nightclub / Bar

Primary Care

Church, Mosque,
etc.

“The Corner” /
block

YMSM

MSM

Lesbian

Bisexual

Transgender

Heterosexual

Minority Men

Minority Women

Beauty / Hair
shop

Venue
Public Spaces

Target Population

Community
Center

Activity

Restaurant /
Coffee House

b.

Comp.**
SUD/COD
Health & wellness
fairs

HIV
Hepatitis
Trauma
Comp.**
SUD/COD
HIV
Hepatitis
Trauma

Other fair types

Comp.**
SUD/COD
Health clinic days

HIV
Hepatitis
Trauma
Comp.**
SUD/COD
HIV
Hepatitis
Trauma

Mobile clinic days

Comp.**
SUD/COD

Day-specific (e.g.,
World AIDS Day)
events

HIV
Hepatitis
Trauma

Structured
socialization

Comp.**
SUD/COD
HIV
Hepatitis
Trauma

Other:

Comp.**
SUD/COD
HIV
Hepatitis
Trauma

c.
Health Promotion
Item

Please enter the average # of health promotion items distributed during this reporting period

Location

Minority
Men

Heterosexual

Transgender

Bisexual

Lesbian

MSM

YMSM

On-site

Health Information
Flyers

Off-site

Safer Sex
Brochures

Off-site

Condoms

Minority
Women

On-site

On-site
Off-site

Hot Line
Information

On-site

Other:

On-site

Off-site

Off-site
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SAMHSA / CSAT HIV PROGRAM(S)

Revised: 10/16/2015

PROGRESS REPORT: HIV GRANTEES
6. Trauma Reporting: (IF APPLICABLE)
a.

Please complete the below table to capture your trauma-informed approach (TIA) / trauma-informed care (TIC) activities

# screened

Traditional
Healers

Support Group

Faith-based

Family
Counseling

Law Enforcement

Court / Judicial

Advocacy

Medical Care

Legal / Legal
Aide

TIC Treatment (e.g.,
ATRIUM, Seeking Safety,
TREM )

Transportation

# referred to
Traumainformed care
(TIC)

Domestic Shelter

Target
Group

# treated

# referred to Ancillary Services
Screening
tool used
(e.g., HITS,
PCL-C,
STaT,
PSSR)

Internal

Minority
Women

External
Internal

Minority
Men

External
Internal

Transgender

External
Internal

Heterosexual

External
Internal

Bisexual
External
Internal

Lesbian
External
Internal

MSM
External
Internal

YMSM
External

b.

Please complete the below table to capture referral system performance data [Mandatory for VITEL Grantees, optional
for all others]  Intimate Partner Violence (IPV) and the Referral System

Indicator

IPV
# clients

Numerator / Denominator

Trauma (all forms)
# clients

# clients referred from your agency
Referral Initiation
# clients seen at your agency
# referred clients seen at receiving agency
Referral Compliance
# clients referred from your agency
Counter-referral
Compliance

7.

# referred clients seen at receiving agency

Disparities Impact Statement (DIS) Reporting: (please submit an updated DIS, if applicable)

Demographics for this period
By Race:
Black / African American
American Indian / Alaskan Native
Asian
Native Hawaiian / Pacific Islander
White
Multi-racial
By Ethnicity:
Hispanic / Latino
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# clients seen at your agency after being counter-referred

Planned

Actual

Planned

By Gender:
Male (M)
Female (F)
Transgender (M)
Transgender (F)

SAMHSA / CSAT HIV PROGRAM(S)

Actual

Planned

Actual

By Sexual Identity:
Heterosexual
Lesbian
Gay
Bisexual

Revised: 10/16/2015

PROGRESS REPORT: HIV GRANTEES
a. What have been your successes and challenges in implementing your DIS strategy?

8.

Additional Information or Data Grantee May Wish to Provide

** Don’t forget to include your Evaluation Report (if available) **
V. Project Summary (this reporting period)
Project Narrative - Provide a summary that includes, but not limited to, the following:
Guidance for developing and writing the narrative
1.

Describe progress and challenge(s) towards achieving your project goals, objectives and targets (new, revised, and/or changed). Detail

2.

Describe the successes and challenges associated with conducting intake and/or follow-up.

3.

Describe the successes and challenges you have been experiencing in operating your referral/transition tracking system. What are you

strategies (presently and/or to be) implemented to overcome those challenges.

doing to maintain/expand your successes and/or to overcome your challenges?
4.

Explain any differences between the number of planned and actual clients seen and between the number of clients served and the number
of intakes. Discuss how the project will meet the annual goal for the number of clients served.

5.

Describe any efforts to expand the project’s capacity to serve the target population(s).

6.

Note any changes in or concerns about your financial status that may affect the implementation or operation of the grant.

7.

Provide copies of any information disseminated to others about the project (e.g., newspaper article; TV or radio coverage; public
presentations including those at local, state, or national conferences; publications).

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SAMHSA / CSAT HIV PROGRAM(S)

Revised: 10/16/2015

PROGRESS REPORT: HIV GRANTEES

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SAMHSA / CSAT HIV PROGRAM(S)

Revised: 10/16/2015