D. Data Dictionary

Page

Variable Label

Variable Name

Variable values

Demographics
Demographics
Demographics
Demographics
Demographics
Demographics
Demographics

Site ID
Reviewer initials
Date of Review
Start time
End time
eUCI
Year of birth

site_id
rev_initials
rev_date
chart_start_time
chart_end_time
client_id
birth_year

Number
Text
Date
Time
Time
Client’s encrypted Unique Client Identifier
Year of birth
Not documented | .
Male | 1
Female | 2
Transgender (man to woman) | 3
Transgender (woman to man) | 4
Transgender (other) | 5
Not documented | .

Demographics Current Gender

gender_current

Demographics Sex at birth

sexatbirth

Demographics Housing status

housing_status

Demographics Race

race

Demographics

race_other

Male | 1
Female | 2
Not documented | .
Stable Permanent Housing | 1
Temporary Housing | 2
Unstable Housing | 3
Not documented | .
American Indian or Alaska Native | 1
Asian | 2
Black or African American | 3
Native Hawaiian or Other Pacific Islander | 4
White | 5
Other | 6
Not documented | .
Text

Public reporting burden for his collection of information is estimated to average 2.5 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.
OMB No. 0906 – xxxx Expiration Date XX/XX/20XX

Page

Variable Label

Variable Name

Variable values

Demographics Ethnicity

ethnicity

Demographics Household income

household_income

Demographics Number of people in
household
Demographics Medical insurance

people_in_house

Demographics Medical insurance
other
Demographics HIV risk factor

med_ins_other

Hispanic/Latino/or Spanish origin | 1
Non-Hispanic/Latino/or Spanish origin | 2
Not documented | .
Enter number
Not documented | .
Enter number
Not documented | .
Private – Employer | 1
Private – Individual | 2
Medicare | 3
Medicaid | 4
CHIP, or other public plan | 5
Veterans Health Administration (VA) | 6
military health care (TRICARE), and other military health care | 7
Indian Health Service | 8
No insurance/uninsured | 0
Other plan (specify) | 9
Not documented | .
Text

Demographics HIV diagnosis year

diagnosis_year

Demographics Date of first visit
(initial intake) for HIV

first_visit

med_ins

risk_factor

Male-to-male sexual contact (MSM) | 1
Injection Drug Use (IDU) | 2
Hemophilia/coagulation disorder | 3
Heterosexual contact | 4
Receipt of blood transfusion, blood components, or tissue | 5
Perinatal transmission | 6
Risk factor not reported or not identified above | .
Date
Not documented | .
Date
Not documented | .

Public reporting burden for his collection of information is estimated to average 2.5 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.
OMB No. 0906 – xxxx Expiration Date XX/XX/20XX

Page

Variable Name

Variable values

Demographics Patient status at end
of review period
Demographics Date of death
(MM/YYYY)
Demographics Services received
during the review
period

patient_status

Demographics No label

patient_model_sub

Alive | 1
Deceased | 2
Date
Date of death unknown | .
HIV care only | 1
HIV and primary care | 2
HIV and other healthcare and supportive services |3
HIV, primary, and other healthcare and supportive services |4
Other healthcare and supportive services provided onsite with medical care clinic |1
Other healthcare and supportive services provided in network/not onsite with medical
care clinic | 2
Other healthcare and supportive services provided onsite with medical care and in
network/not onsite with medical care clinic | 3

Medical Visits

Medical Visits

Medical Visits
Medical Visits
Medical Visits

Variable Label

date_death
patient_model_care

Date of visit with HIV visit_date
medical provider with
prescribing privileges:
Client did not show up no_show
for the visit

Date
Not Documented | .

Systolic
bp_sys
Diastolic
bp_dia
Is client sexually active sexually_active

Number
Number
Yes | 1
No | 0
Not documented | .

Client did not show up for visit | 1

Public reporting burden for his collection of information is estimated to average 2.5 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.
OMB No. 0906 – xxxx Expiration Date XX/XX/20XX

Page

Variable Label

Medical Visits

Date sexual history
history_discussed_date
discussed
pregnant
If female, is patient
pregnant at this visit?

Medical Visits

Medical Visits

Medical Visits

Medical Visits

Medical Visits

Medical Visits
Medical Visits

First noted date of
pregnancy, if
applicable
Pregnancy Outcome

Variable Name

pregnancy_date

pregnancy_outcome

Mental health
mental_screen
screening done during
the visit
Type of mental health mental_screen_test
screening tests

Type of mental health mental_screen_other
screening tests other
Was a substance use sub_screen
screening done during
the visit

Variable values
Date
Not Documented | .
Yes | 1
No | 0
Not documented | .
Date
N/A Pregnancy ongoing | 1
Not applicable or not documented | .
Pregnancy ongoing | 1
Live birth | 2
Pregnancy did not result in live birth | 3
Not applicable/ not documented | .
Yes | 1
No | 0
Not documented | .
PHQ-2 | 1
SAMISS | 2
PHQ-9 | 3
CES-D | 4
GAD-7 | 5
Abbreviated PCL-C | 6
Kessler 6 or 10 | 7
Beck Screeners | 8
Other | 9
Not Documented | .
Text
Yes | 1
No | 0
Not documented | .

Public reporting burden for his collection of information is estimated to average 2.5 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.
OMB No. 0906 – xxxx Expiration Date XX/XX/20XX

Page

Variable Label

Variable Name

Variable values

Medical Visits

Type of screening
performed

sub_screen_test

NIDA Quick Screen V1.0 and NIDA ASSIST V2.0 Drug Abuse Screening Test (DAST-10) | 1
MAST | 2
Triage Assessment for Addictive Disorders (TAAD) | 3
CAGE | 4
UNCOPE | 5
CRAFFT | 6
Other | 7
Not documented |.

Medical Visits

Medical Visits

Substance screening - sub_screen_other
text
other
No documented
substance_abuse_not_docu No documented history of substance abuse | 1
history of substance
mented
sub_usedVISITNUMBER []
alc |1
mar | 2
benzo | 3
coca | 4
crack | 5
hallu | 6
heroin | 7
keta | 8
opi | 9
amphet | 10
other | 11
Substance used - other sub_used_other
Text

Medical Visits

Results of screening

Medical Visits

alc_screen_results

Last use < 3 months | 1
Last use >= 3 - < 6 months | 2
Last use >= 6 - < 12 months | 3
Last use > 12 months | 4
No time period specified | .

Public reporting burden for his collection of information is estimated to average 2.5 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.
OMB No. 0906 – xxxx Expiration Date XX/XX/20XX

Page

Variable Label

Variable Name

Variable values

Medical Visits

Results of screening

mar_screen_results

Last use < 3 months | 1
Last use >= 3 - < 6 months | 2
Last use >= 6 - < 12 months | 3
Last use > 12 months | 4
No time period specified | .

Medical Visits

Results of screening

benzo_screen_results

Last use < 3 months | 1
Last use >= 3 - < 6 months | 2
Last use >= 6 - < 12 months | 3
Last use > 12 months | 4
No time period specified | .

Medical Visits

Results of screening

coca_screen_results

Last use < 3 months | 1
Last use >= 3 - < 6 months | 2
Last use >= 6 - < 12 months | 3
Last use > 12 months | 4
No time period specified | .

Medical Visits

Results of screening

crack_screen_results

Last use < 3 months | 1
Last use >= 3 - < 6 months | 2
Last use >= 6 - < 12 months | 3
Last use > 12 months | 4
No time period specified | .

Medical Visits

Results of screening

hallu_screen_results

Last use < 3 months | 1
Last use >= 3 - < 6 months | 2
Last use >= 6 - < 12 months | 3
Last use > 12 months | 4
No time period specified | .

Public reporting burden for his collection of information is estimated to average 2.5 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.
OMB No. 0906 – xxxx Expiration Date XX/XX/20XX

Page

Variable Label

Variable Name

Variable values

Medical Visits

Results of screening

heroin_scren_results

Last use < 3 months | 1
Last use >= 3 - < 6 months | 2
Last use >= 6 - < 12 months | 3
Last use > 12 months | 4
No time period specified | .

Medical Visits

Results of screening

keta_screen_results

Last use < 3 months | 1
Last use >= 3 - < 6 months | 2
Last use >= 6 - < 12 months | 3
Last use > 12 months | 4
No time period specified | .

Medical Visits

Results of screening

opi_screen_results

Last use < 3 months | 1
Last use >= 3 - < 6 months | 2
Last use >= 6 - < 12 months | 3
Last use > 12 months | 4
No time period specified | .

Medical Visits

Results of screening

amphet_screen_results

Last use < 3 months | 1
Last use >= 3 - < 6 months | 2
Last use >= 6 - < 12 months | 3
Last use > 12 months | 4
No time period specified | .

Medical Visits

Results of screening

other_screen_results

Last use < 3 months | 1
Last use >= 3 - < 6 months | 2
Last use >= 6 - < 12 months | 3
Last use > 12 months | 4
No time period specified | .

Medical Visits

Referral date for
services

alc_ref_date

Date
Not applicable/ Not documented | .

Public reporting burden for his collection of information is estimated to average 2.5 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.
OMB No. 0906 – xxxx Expiration Date XX/XX/20XX

Page

Variable Label

Variable Name

Variable values

Medical Visits

mar_ref_date

Medical Visits

Referral date for
services
Referral date for
services
Referral date for
services
Referral date for
services
Referral date for
services
Referral date for
services
Referral date for
services
Referral date for
services
Referral date for
services
Referral date for
services
Treatment status

Medical Visits

Treatment status

mar_treat_status

Date
Not applicable/ Not documented | .
Date
Not applicable/ Not documented | .
Date
Not applicable/ Not documented | .
Date
Not applicable/ Not documented | .
Date
Not applicable/ Not documented | .
Date
Not applicable/ Not documented | .
Date
Not applicable/ Not documented | .
Date
Not applicable/ Not documented | .
Date
Not applicable/ Not documented | .
Date
Not applicable/ Not documented | .
No treatment or referral | 1
Patient refused referral or treatment | 2
In treatment at clinic/facility |3
In treatment at location outside clinic/facility | 4
Not documented | .
No treatment or referral | 1
Patient refused referral or treatment | 2
In treatment at clinic/facility |3
In treatment at location outside clinic/facility | 4
Not documented | .

Medical Visits
Medical Visits
Medical Visits
Medical Visits
Medical Visits
Medical Visits
Medical Visits
Medical Visits
Medical Visits

benzo_ref_date
coca_ref_date
crack_ref_date
hallu_ref_date
heroin_ref_date
keta_ref_date
opi_ref_date
amphet_ref_date
other_ref_date
alc _treat_status

Public reporting burden for his collection of information is estimated to average 2.5 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.
OMB No. 0906 – xxxx Expiration Date XX/XX/20XX

Page

Variable Label

Variable Name

Variable values

Medical Visits

Treatment status

coca_treat_status

Medical Visits

Treatment status

crack_treat_status

Medical Visits

Treatment status

hallu_treat_status

Medical Visits

Treatment status

heroin_treat_status

Medical Visits

Treatment status

keta_treat_status

Medical Visits

Treatment status

opi_treat_status

No treatment or referral | 1
Patient refused referral or treatment | 2
In treatment at clinic/facility |3
In treatment at location outside clinic/facility | 4
Not documented | .
No treatment or referral | 1
Patient refused referral or treatment | 2
In treatment at clinic/facility |3
In treatment at location outside clinic/facility | 4
Not documented | .
No treatment or referral | 1
Patient refused referral or treatment | 2
In treatment at clinic/facility |3
In treatment at location outside clinic/facility | 4
Not documented | .
No treatment or referral | 1
Patient refused referral or treatment | 2
In treatment at clinic/facility |3
In treatment at location outside clinic/facility | 4
Not documented | .
No treatment or referral | 1
Patient refused referral or treatment | 2
In treatment at clinic/facility |3
In treatment at location outside clinic/facility | 4
Not documented | .
No treatment or referral | 1
Patient refused referral or treatment | 2
In treatment at clinic/facility |3
In treatment at location outside clinic/facility | 4
Not documented | .

Public reporting burden for his collection of information is estimated to average 2.5 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.
OMB No. 0906 – xxxx Expiration Date XX/XX/20XX

Page

Variable Label

Variable Name

Variable values

Medical Visits

Treatment status

amphet_treat_status

Medical Visits

Treatment status

other_treat_status

Medical Visits

Result of referral

alc_treat_result

Medical Visits

Result of referral

mar_treat_result

Medical Visits

Result of referral

coca_treat_result

Medical Visits

Result of referral

crack_treat_result

No treatment or referral | 1
Patient refused referral or treatment | 2
In treatment at clinic/facility |3
In treatment at location outside clinic/facility | 4
Not documented | .
No treatment or referral | 1
Patient refused referral or treatment | 2
In treatment at clinic/facility |3
In treatment at location outside clinic/facility | 4
Not documented | .
Completed | 1
Actively In treatment | 2
Not completed | 3
Refused | 4
Not documented | .
Completed | 1
Actively In treatment | 2
Not completed | 3
Refused | 4
Not documented | .
Completed | 1
Actively In treatment | 2
Not completed | 3
Refused | 4
Not documented | .
Completed | 1
Actively In treatment | 2
Not completed | 3
Refused | 4
Not documented | .

Public reporting burden for his collection of information is estimated to average 2.5 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.
OMB No. 0906 – xxxx Expiration Date XX/XX/20XX

Page

Variable Label

Variable Name

Variable values

Medical Visits

Result of referral

hallu_treat_result

Medical Visits

Result of referral

heroin_treat_result

Medical Visits

Result of referral

keta_treat_result

Medical Visits

Result of referral

opi_treat_result

Medical Visits

Result of referral

amphet_treat_result

Medical Visits

Result of referral

other_treat_result

Completed | 1
Actively In treatment | 2
Not completed | 3
Refused | 4
Not documented | .
Completed | 1
Actively In treatment | 2
Not completed | 3
Refused | 4
Not documented | .
Completed | 1
Actively In treatment | 2
Not completed | 3
Refused | 4
Not documented | .
Completed | 1
Actively In treatment | 2
Not completed | 3
Refused | 4
Not documented | .
Completed | 1
Actively In treatment | 2
Not completed | 3
Refused | 4
Not documented | .
Completed | 1
Actively In treatment | 2
Not completed | 3
Refused | 4
Not documented | .

Public reporting burden for his collection of information is estimated to average 2.5 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.
OMB No. 0906 – xxxx Expiration Date XX/XX/20XX

Page

Variable Label

Variable Name

Variable values

Medical Visits

Treatment modality

treatment_mod

Medical Visits

treatment_mod_other

Medical Visits

Treatment modality other
Current MAT use

Medication-Assisted Treatment (MAT) | 1
Detox | 2
Acupuncture | 3
Licensed counselor | 4
Peer support staff | 5
Narcotics Anonymous (NA) | 6
Alcoholics Anonymous (AA) | 7
Halfway/Sober House | 8
Counseled by provider | 9
Syringe services | 10
Other (describe) | 11
Not documented | .
Text

Medical Visits

Type of MAT

type_of_mat

Medical Visits

Type of MAT Other

type_of_mat_other

Medical Visits

Administration of
NARCAN to patient

narcan

mat_use

Yes | 1
No | 0
Unknown | .
Buprenorphine/ Naloxone (Suboxone) | 1
Buprenorphine | 2
Oral Naltrexone | 3
Long acting injectable Naltrexone | 4
Methadone | 5
Disulfiram | 6
Acamprosate | 7
Other | 8
Not documented | .
Text
Yes | 1
No | 0
Not documented | .

Public reporting burden for his collection of information is estimated to average 2.5 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.
OMB No. 0906 – xxxx Expiration Date XX/XX/20XX

Page

Variable Label

Variable Name

Medical Visits

No documented
history of tobacco
Type of tobacco

tobacco_use_not_documen No documented history of substance abuse | 1
ted
tob_typeVISITNUMBER []
Cigarettes | 1
Cigar/cigarillo | 2
Vaporizer | 3
Snuff | 4
Other | 5
tob_type_other
Text

Medical Visits

Medical Visits
Medical Visits

Type of tobacco other
Tobacco and nicotine
use history

Variable values

tob_history_cigarettes

Last use < 3 months | 1
Last use >= 3 - < 6 months | 2
Last use >= 6 - < 12 months | 3
Last use > 12 months | 4
No time period specified | .

Medical Visits

Tobacco and nicotine
use history

tob_history_cigar

Last use < 3 months | 1
Last use >= 3 - < 6 months | 2
Last use >= 6 - < 12 months | 3
Last use > 12 months | 4
No time period specified | .

Medical Visits

Tobacco and nicotine
use history

tob_history_vaporizer

Last use < 3 months | 1
Last use >= 3 - < 6 months | 2
Last use >= 6 - < 12 months | 3
Last use > 12 months | 4
No time period specified | .

Public reporting burden for his collection of information is estimated to average 2.5 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.
OMB No. 0906 – xxxx Expiration Date XX/XX/20XX

Page

Variable Label

Variable Name

Variable values

Medical Visits

Tobacco and nicotine
use history

tob_history_snuff

Last use < 3 months | 1
Last use >= 3 - < 6 months | 2
Last use >= 6 - < 12 months | 3
Last use > 12 months | 4
No time period specified | .

Medical Visits

Tobacco and nicotine
use history

tob_history_other

Last use < 3 months | 1
Last use >= 3 - < 6 months | 2
Last use >= 6 - < 12 months | 3
Last use > 12 months | 4
No time period specified | .

Medical Visits

Cessation counseling
at visit

tob_counseling_cigarettes

Medical Visits

Cessation counseling
at visit

tob_counseling_cigar

Medical Visits

Cessation counseling
at visit

tob_counseling_vape

Medical Visits

Cessation counseling
at visit

tob_counseling_snuff

Medical Visits

Cessation counseling
at visit

tob_counseling_other

Yes | 1
No | 0
Not documented | .
Yes | 1
No | 0
Not documented | .
Yes | 1
No | 0
Not documented | .
Yes | 1
No | 0
Not documented | .
Yes | 1
No | 0
Not documented | .

Public reporting burden for his collection of information is estimated to average 2.5 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.
OMB No. 0906 – xxxx Expiration Date XX/XX/20XX

Page

Variable Label

Variable Name

Variable values

Medical Visits

Tobacco and nicotine
treatment status

tob_treatment_cigarettes

Medical Visits

Tobacco and nicotine
treatment status

tob_treatment_cigar

Medical Visits

Tobacco and nicotine
treatment status

tob_treatment_vape

Medical Visits

Tobacco and nicotine
treatment status

tob_treatment_snuff

Medical Visits

Tobacco and nicotine
treatment status

tob_treatment_other

No treatment or referral | 0
Patient refused referral or treatment | 1
Referred to treatment | 2
In treatment at clinic/facility | 3
In treatment at location outside clinic/facility | 4
Not specified | .
No treatment or referral | 0
Patient refused referral or treatment | 1
Referred to treatment | 2
In treatment at clinic/facility | 3
In treatment at location outside clinic/facility | 4
Not specified | .
No treatment or referral | 0
Patient refused referral or treatment | 1
Referred to treatment | 2
In treatment at clinic/facility | 3
In treatment at location outside clinic/facility | 4
Not specified | .
No treatment or referral | 0
Patient refused referral or treatment | 1
Referred to treatment | 2
In treatment at clinic/facility | 3
In treatment at location outside clinic/facility | 4
Not specified | .
No treatment or referral | 0
Patient refused referral or treatment | 1
Referred to treatment | 2
In treatment at clinic/facility | 3
In treatment at location outside clinic/facility | 4
Not specified | .

Public reporting burden for his collection of information is estimated to average 2.5 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.
OMB No. 0906 – xxxx Expiration Date XX/XX/20XX

Page

Variable Label

Variable Name

Variable values

Medical Visits

Tobacco/nicotine
medication used by
patient

tob_meds

Medical Visits

HCV Treatment Status hcv_treatment

Medical Visits
Medicines

Diagnosis of other co- comorbidities
morbidities: (Type
Medication name
medication_name

Nicotine patch | 1
Nicotine gum | 2
Chantix | 3
Wellbutrin | 4
Not documented | .
In treatment | 1
Completed treatment | 2
Incomplete treatment | 3
Not documented | .
See values on next tab

Medicines

Medication start date medication_start_date

Date
Not documented | .

Medicines

Medication stop date

medication_end_date

Date
Not documented | .

Lab

Date

testing_cd4count_date

Lab

CD4 result mm3 = µL

cd4_result_mm3_

Lab

CD4 result %

cd4_result_percent

Lab

Viral load Date

testing_viral_date

Lab

Result

testing_viral_load_option

Date
Not documented | .
Number
Not documented | .
Number
Not documented | .
Date
Not documented | .
<|1
>|2
=|3

Type ahead look up assisted text

Public reporting burden for his collection of information is estimated to average 2.5 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.
OMB No. 0906 – xxxx Expiration Date XX/XX/20XX

Page

Variable Label

Variable Name

Variable values

Lab

Copies/mL

testing_viral_load

Number

Lab

Glucose Regulation
Test Date
Type
Hemoglobin A1-C
Result (%)
Lipid test date

testing_a1c_date

total_chol

Lab

Total Cholesterol
(mg/dL)
HDL (mg/dL)

Lab

LDL (mg/dL)

ldl_chol

Lab

Triglycerides (mg/dL)

trig_chol

Lab

Chem panel test date

testing_chem_date

Lab

TB screening test date testing_tb_date

Lab

TB screening test type tb_type

Lab

TB screening test
results

Date
Not documented | .
Hemoglobin A1c | 1
Number
Not documented | .
Date
Not documented | .
Number
Not documented | .
Number
Not documented | .
Number
Not documented | .
Number
Not documented | .
Date
Not documented | .
Date
Not documented | .
Not applicable, patient has a history of TB or a history of a (+) PPD result or (+) IGRA test |
0
PPD | 1
IGRA testing (Quantiferon or T-spot) | 2
Chest x-ray | 3
Not documented | .
Positive | 1
Negative | 0
Indeterminate (for IGRA) | 2
Not documented | .

Lab
Lab
Lab
Lab

a1c_type
a1c_result
testing_lipid_date

hdl_chol

tb_results

Public reporting burden for his collection of information is estimated to average 2.5 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.
OMB No. 0906 – xxxx Expiration Date XX/XX/20XX

Page

Variable Label

Variable Name

Variable values

Lab

testing_colorectal_date

Lab

Colorectal cancer
screening date
Type

Lab

Pregnancy test

pregnancy_test_date

Lab

Date of HPV screening hpv_date
test
Result of HPV
hpv_result
screening test

Date
Not documented | .
Stool test | 1
Flexible sigmoidoscopy | 2
Colonoscopy | 3
CT colonograph/virtual colonoscopy | 4
Not documented | .
Date
Not documented | .
Date
Not documented | .
Detected | 1
Not-detected | 0
Not documented | .
Date
Not documented | .
Not applicable (for women with hysterectomy without residual cervix) | 0

Lab

colorectal_type

Lab

Cervical pap smear
date

pap_date

Lab

Result of all cervical
PAP smear

pap_result

Lab

Colposcopy date

colpo_date

Unsatisfactory | 1
Nilm (negative for intraepithelial lesion or malignancy) | 2
Ascus (atypical squamous cells of undetermined significance) | 3
Lgsil (low grade squamous intraepithelial lesion) | 4
AGC (atypical glandular cells) | 5
Atypical endometrial cells | 6
ASC-H (atypical squamous cells, cannot exclude high grade) | 7
Hgsil (high grade squamous intraepithelial lesion) | 8
No result listed | .
Date
Not documented | .
Hysterectomy non-cancerous | 0

Public reporting burden for his collection of information is estimated to average 2.5 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.
OMB No. 0906 – xxxx Expiration Date XX/XX/20XX

Page

Variable Label

Variable Name

Variable values

Lab

Referral date (If a
colposcopy result is
indicated without a
screening date)
Breast cancer
screening date
Breast cancer
screening type

colpo_referral

Date
Not documented | .

breast_cancer_date

Date
Not documented | .
Mammogram | 1
MRI | 2
Not documented | .
Date
Not documented | .
Date
Not documented | .
Positive | 1
Negative | 0
Not documented | .

Lab
Lab

breast_cancer_screen

Lab

Bone density test date bone_test

Lab

Hepatitis A IgG
screening date
Hepatitis A IgG
screening results

testing_hepa_igg_date

Total antibody (IgM
and IgG) screening
Total antibody (IgM
and IgG) screening
results

hepa_igmigg_date

Lab

Lab
Lab

Lab
Lab

Lab

hepa_igg_results

hepa_igmigg_results

Date
Not documented | .
Positive | 1
Negative | 0
Not documented | .

HBV surface antibody testing_hbv_sab_date
screening date
HBV surface antibody hbv_sab_results
results

Date
Not documented | .
Positive | 1
Negative | 0
Not documented | .

HBV core antibody
screening date

Date
Not documented | .

hbv_ca_date

Public reporting burden for his collection of information is estimated to average 2.5 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.
OMB No. 0906 – xxxx Expiration Date XX/XX/20XX

Page

Variable Label

Variable Name

Variable values

Lab

HBV core antibody
results

hbv_ca_results

Positive | 1
Negative | 0
Not documented | .

Lab

HBV surface antigen
screening date
HBV surface antigen
results

hbv_sag_date

Date
Not documented | .
Positive | 1
Negative | 0
Not documented | .

HBV DNA Screening
date
HBV DNA results

hbv_dna_date

Lab

Lab

Lab
Lab
Lab

hbv_sag_results

hbv_dna_results_option

HBV DNA results (in
hbv_dna_results
International units/mL)
HCV screening test
testing_hcv_date
date
HCV screening test
hcv_type
type

Lab

Results of HCV
antibody test

hcv_ab_results

Lab

Results of HCV RNA
test

hcv_rna_results

Lab

HCV genotyping test
date

hdc_gen_date

Date
Not documented | .
<|1
>|2
=|3
Number
Not documented | .
Date
Not documented | .
HCV antibody test | 1
HCV RNA test | 2
Not documented | .
Positive | 1
Negative | 0
Not documented | .
Detectable | 1
Below Detectable Limits | 2
Negative | 3
Not documented | ..
Date
Not documented | .

Public reporting burden for his collection of information is estimated to average 2.5 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.
OMB No. 0906 – xxxx Expiration Date XX/XX/20XX

Page

Variable Label

Variable Name

Lab

HCV genotype testing hcv_gen_results
results

Lab

Liver test date

testing_liver_date

Lab

Liver biopsy

liver_biopsy

Lab

Liver imaging

liver_imaging

Lab

Serum Liver
Biomarkers

liver_biomarkers

Lab

Syphilis screening date testing_syph_date

Lab

Syphilis screen results syph_results

Lab

Chlamydia screening
date

chlam_date

Variable values
Genotype 1 | 1
Genotype 2 | 2
Genotype 3 | 3
Genotype 4 | 4
Genotype 5 | 5
Not documented | .
Date
Not documented | .
Liver biopsy | 1
Fibroscan(Transient Elastography) |1
Acoustic radiation force impulse (ARFI) Acuson S2000 | 2
Real-time tissue elastophgraphy (RTE) HI VISION, Preirus | 3
Magnetic Resonance Elastography | 4
Fibrotest | 1
ActiTest | 2
Hepascore | 3
Fibrospect II | 4
European Liver Fibrosis Panel | 5
AST/ALT Ratio (hand calculated) | 6
AST and Platelet with APRI (lab test) | 7
AST: platelet ratio (hand calculated) | 8
Date
Not documented | .
Reactive | 1
Non-reactive | 2
Not documented | .
Date
Not documented | .

Public reporting burden for his collection of information is estimated to average 2.5 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.
OMB No. 0906 – xxxx Expiration Date XX/XX/20XX

Page

Variable Label

Variable Name

Variable values

Lab

Chlamydia screening
site

chlam_site

Lab

Chlamydia screening
results

chlam_results

Lab

Gonorrhea screening ghon_date
date
Gonorrhea screening ghon_results
results

Throat | 1
Anal/rectal | 2
Vaginal | 3
Urine | 4
Not documented | .
Positive | 1
Negative | 0
Not documented | .
Date
Not documented | .
Positive | 1
Negative | 0
Not documented | .
Throat | 1
Anal/ Rectal | 2
Vaginal | 3
Urine | 4
Not documented | .

Lab

Lab

Gonorrhea screening
site

ghon_site

Lab

Gonorrhea type of
specimen

ghon_spec_type

Vaccine

Hepatitis A vaccine

hepa_dose1_date

Vaccine

Hepatitis A vaccine

hepa_dose2_date

Vaccine

Hepatitis B vaccine

hep_b_dose1_type

Vaccine

Hepatitis B vaccine

hep_b_dose1_date

Nucleic acid amplification test (NAAT) | 1
Culture | 2
Not documented | .
Date
Not documented | .
Date
Not documented | .
Engerix | 1
Recombivax | 2
Heplisav-B | 3
Date
Not documented | .

Public reporting burden for his collection of information is estimated to average 2.5 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.
OMB No. 0906 – xxxx Expiration Date XX/XX/20XX

Page

Variable Label

Variable Name

Variable values

Vaccine

Hepatitis B vaccine

hep_b_dose2_type

Vaccine

Hepatitis B vaccine

hep_b_dose2_date

Vaccine

Hepatitis B vaccine

hep_b_dose3_type

Engerix | 1
Recombivax | 2
Heplisav-B | 3
Date
Not documented | .
Engerix | 1
Recombivax | 2

Vaccine

Hepatitis B vaccine

hep_b_dose3_date

Vaccine

hep_ab_dose1_type

Vaccine

Hepatitis A and B Dose
2 type
Hepatitis A and B Dose
1 date
Hepatitis A and B Dose
2 type
Hepatitis A and B Dose
2 date
Hepatitis A and B Dose
3 type
Hepatitis A and B Dose
3 date
Influenza vaccine date

Vaccine

Remarks

remarks

Vaccine
Vaccine
Vaccine
Vaccine
Vaccine

hep_ab_dose1_date
hep_ab_dose2_type
hep_ab_dose2_date
hep_ab_dose3_type
hep_ab_dose3_date
vaccines_Influenza_date

Date
Not documented | .
Twinrix | 1
Date
Not documented | .
Twinrix | 1
Date
Not documented | .
Twinrix | 1
Date
Not documented | .
Date
Not documented | .

Public reporting burden for his collection of information is estimated to average 2.5 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.
OMB No. 0906 – xxxx Expiration Date XX/XX/20XX