Cluster Close-out Form

National HIV Surveillance System (NHSS)

Attachment 3h.
Cluster Close-Out Form

Form Approved
OMB No. 0920-0573
Expiration Date: XX/XX/XXXX
Cluster Report: Cluster Annual/Closeout Report (Complete for all clusters, regardless of method of detection)
Jurisdiction Name:
Person Completing Report:
1. Date form completed:
3. National Cluster ID (if applicable)

0

Low morbidity jurisdiction?
Email address:
2. Local Cluster ID entered into eHARS

0

4. Are response activities for this cluster
currently ongoing?

6. Size of cluster at closeout/current cluster size

5. Date cluster investigation and
response activities closed: (complete
only if the answer to #1 is 'no')
Transmission cluster (within your
jurisdiction):**
Risk network (persons not known to be
HIV-infected residing in your
jurisdiction):**

7. Reason(s) for closeout (describe): (complete only if the answer to #1 is 'no')
8. Since the time of cluster detection, were any of the following investigation and/or intervention activities conducted:
8a. Partner Services interviews for
8b. Partner Services re-interviews for
persons in the transmission cluster who
persons in the transmission cluster who
were not previously interviewed?
were previously interviewed?
8c. Social network interviews and/or
8d. Second-generation interviews
testing?
(interviews of partners of partners)?
8e. Targeted testing events?
8f. Medical chart reviews?
8g. Qualitative interviews?
8h. Messaging activities? (If yes, please
describe using the box to the right)
8g. Other activities (If yes, please describe
using the box to the right)
9a*. How many persons in your
jurisdiction did not have evidence of viral
suppression at the time of identification
as part of the cluster?**
10a^.How many persons in your
jurisdiction were HIV-negative or had
unknown HIV status at the time of
identification as part of the risk
network?**

9b*. Among persons who did not have
evidence of viral suppression at the time
of identification as part of the cluster
(9a), how many achieved viral
suppression within six months?**
10b^. Of persons who were HIV-negative
or had unknown HIV status at the time
of identification as part of the risk
network (10a), how many were
tested/re-tested within 6 months?**
10c^. Of persons who were HIV-negative
or had unknown HIV status at the time
of identification as part of the risk
network (10a), how many were
tested/re-tested at greater than 6
months?**

11^. Results of testing and re-testing for persons in 10a:
(Report only numeric data for each category below.)
1

11a. No. New Positive :
11b. Acute: (subset of 11a)
11c. Recent (not acute): (subset of 11a)
11d. No. Negative:
11e. Referred for PrEP: (subset of 11d)
11f. No. Tested but result Unknown:
1

1

11g. No. Previous Positive :
11h. No. Refused testing:
11i. No. Not Located:
11j. No. Outside Jurisdiction:
11k. No. Not tested because person was
deceased:
11l. No. not tested for other reason:

These persons should be included as members of the larger transmission cluster

12a. How many persons in your
jurisdiction were HIV-negative and not on
PrEP at the time of identification as part
of the risk network?**

12b. Of all persons who were HIVnegative and not on PrEP at the time of
identification as part of the risk network
(12a), how many were screened for PrEP
within 6 months?**
12c Of all persons who were screened
for PrEP within 6 months(12b), how
many were determined to be eligible?**
12d. Of all persons who were eligible for
PrEP within 6 months (12c), how many
were referred?**

0

13. What key lessons were learned through the course of investigating this
cluster?
14. Please describe the impact of cluster investigation and response activities on
current health department policies and processes (i.e. whether any
enhancements were made to regular HIV prevention and treatment processes
such as provision of case management services or expansion of PrEP resources,
whether communication within the health department or interactions between
local and state health departments changed, whether the cluster was used to
advocate for policy changes, whether additional resources were required to
respond to this particular cluster, etc.).
15. Briefly describe your current level of concern for this cluster and why ongoing
response is still needed. If the cluster response has been closed, instead describe
how you will continue monitoring the cluster for future growth.
^This information can be pulled directly from your partner services database and provided as a separate excel attachment rather than reporting separately here, if
your system has the functionality to do this.
*This information can be pulled directly from eHARS and provided as a separate excel attachment rather than reporting separately here.
**For guidance on how to complete these fields for non-molecular clusters, see the Cluster Report Instructions document.
END OF CLUSTER ANNUAL/CLOSEOUT REPORT FORM.

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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 Information Collection Review Office,
1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30329; ATTN: PRA (0920-0573).