Form 2 2018_Service_Provider_Form_Screenshots

Variable	Recommendation
ID #9: Categories that best describes the agency’s racial/ethnic characteristics	Remove
ID #10: Number of paid staff, in full-time equivalents (FTEs), funded by RWHAP	Remove
ID #14: Number who tested NEGATIVE and received post-test counseling	Remove
ID #16: Number who tested POSITIVE and received post-test counseling	Remove
ID #11: Status of clinical quality management program for assessing HIV core medical services	Change variable name to Select the status of your agency’s clinical quality management program; Change response options: Response Options: Not applicable Do not have a clinical quality management program - add Clinical quality management program initiated this reporting period; Previously established clinical quality management program; Previously established program with new quality standards added this reporting period

We added three new responses/questions below in 2017:

1. Within your organization/agency, identify the number of physicians, nurse practitioners, or physician assistants who obtained a Drug Addiction Treatment Act of 2000 (DATA) waiver to treat opioid use disorder with medications (medication assisted treatment [MAT], e.g. buprenorphine) specifically approved by the U.S. Food and Drug Administration (FDA).;

2. How many of the above physicians, nurse practitioners, or physician assistants prescribed MAT (e.g. buprenorphine, vivitrol) for opioid use disorders in the reporting year?; and

3. How many clients were treated with MAT during the reporting period?

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 0906-XXXX. Public reporting burden for this collection of information is estimated to average 13 hours per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14N136B, Rockville, Maryland, 20857.

Items 1 – 2: If the information in Item 1 or Item 2 is incorrect, it must be corrected. Providers may edit the information by selecting the “edit” link next to the Item.

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Item 3: Select the provider type that best describes the organization. After the initial submission, this item will be pre-populated in subsequent data reports.

Item 4: Indicate if your organization received funding under Section 330 of the Public Health Service Act during the given reporting period.

Item 5: Select the category that best describes your organization’s ownership status. If “Private, nonprofit” is selected, you must answer Item b. After the initial submission, this item will be pre-populated in subsequent data reports.

Item 6: Indicate if your organization received Minority AIDS Initiative (MAI) funds during the given reporting period.

Item 7: Enter the amount of Ryan White Program funds expended on oral health care during the given reporting period

7*: Within your organization/agency, identify the number of physicians, nurse practitioners, or physician assistants who obtained a Drug Addiction Treatment Act of 2000 (DATA) waiver to treat opioid use disorder with medications (medication assisted treatment [MAT], e.g. buprenorphine) specifically approved by the U.S. Food and Drug Administration (FDA).

7**: How many of the above physicians, nurse practitioners, or physician assistants prescribed MAT (e.g. buprenorphine, vivitrol) for opioid use disorders in the reporting period?

7***: How many clients were treated with MAT during the reporting period?

Item 8: Grantee/contract information: This list of contracts is populated with information provided by Ryan White HIV/AIDS Program grantees. The contract reference, if specified, will help you report the data associated with a particular contract. (Note: For the purposes of the Ryan White Data Report, “contracts” include formal contracts, memorandum of understanding, and other agreements.)

Services: This link opens another screen (see page 3).

• Select the services delivered under each agreement during the given reporting period.

Please see the following pages (pgs. 5-6) for magnified views of each service section.

• Please select the administrative services delivered under this agreement during the given reporting period (check all that apply).

• Please select the core medical services delivered under this agreement during the given reporting period (check all that apply).

• Please select the support services delivered under this agreement during the given reporting period (check all that apply).

• Please check the box if this agency delivered HIV Counseling and Testing Services during the given reporting period.

Items 9 through 11 – Core Medical Services

If you indicated in Item 8 (services delivered), that you delivered ONLY “Administrative Services” and/or “Support Services,” then Items 9 through 17 are not required.

You will STOP here.  

Conversely, if you indicated that you did deliver “Core Medical Services,” then Items 9 through 11 will be required.

Item 9: Select the categories that best describe your organization. – delete

Item 10: Report the number of paid staff, in full-time equivalents (FTEs), funded by the Ryan White HIV/AIDS Program during the given reporting period. – delete

Item 11: Select the status of your agency’s clinical quality management program- change response option from Not applicable to Do not have a clinical quality management program – modify

Items 12–17: If a grantee indicates in Item 8 that your organization was contracted to provide HIV counseling and testing services during the given reporting period, your organization then Items 12 through 17 ARE required.

Conversely, if you indicated that you did NOT deliver “HIV Counseling and Testing”, then Items 12 through 17 will be disabled.

Item 12 – Number Tested for HIV

Item 13 – Number of Test Results Negative

Item 14 – Number of Results Negative & Received Counseling - delete

Item 15 – Number of Test Results Positive

Item 16 – Number of Test Results Positive & Received Counseling – delete

Item 17 – Number of Test Results Positive and Referred

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