Form HIV Testing Retros HIV Testing Retros HIV Testing Retrospective Reporting Tool

OMB No. 0930-0xxx

Expiration Date: xx/xx/xxxx

Public Burden Statement: 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.  The OMB control number for this project is 0930-0XXX.  Public reporting burden for this collection of information is estimated to average 15 minutes per respondent, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. This information will be collected once only. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to SAMHSA Reports Clearance Officer, 1 Choke Cherry Road, Room 2-1057, Rockville, Maryland, 20857.

HIV Testing Retrospective Reporting Tool

Federal Fiscal Year 2015 (10/1/2014 – 9/30/2015)

1. Date Entered |____|____| / |____|____| / |____|____|____|____|

Month Day Year

2. During Federal FY 2015, how many people received an HIV test using CSAP/MAI funds? _______

2. During Federal FY 2015, how many people received an HIV test for the first time using CSAP/MAI funds? _______

2. Please break down each of the above totals by demographic category in the columns below. The number tested for any given demographic category should not exceed the totals as reported above in 2 and 3.

Demographic Categories		Received an HIV test using CSAP/MAI funds	Received an HIV test for the first time using CSAP/MAI funds
Gender	Female
	Male
	Transgender
	Unknown
Ethnicity	Hispanic
	Non-Hispanic
	Unknown
Race	African American/Black
	American Indian or Alaska Native
	Asian
	Native Hawaiian or Other Pacific Islander
	White
	Multiracial
	Other
	Unknown
Age	Ages 12-17
	Ages 18 or Older
	18-24
	25-34
	35-44
	45-54
	55-64
	65+
	Unknown

2. Of the total entered in 2 [i.e., total number of people who received an HIV test using CSAP/MAI funds],

   1. How many were homeless or unstably housed?

_______

2. How many were tested directly by the grantee organization or partner organization? _______

3. How many tested positive for HIV? _____

4. How many were informed of their HIV status? ______

5. Of those who tested positive for HIV, how many were referred to treatment? ______

2. During Federal FY 2015, how much was spent on HIV testing? ____

2. During Federal FY 2015, how many HIV test kits did your agency purchase using CSAP/MAI grant funds? _____