Form 1 EHE Triannual Module_OMB mockup - FORM

OMB No. 0906-XXXX

Expires: XX/XX/202X

Proposed E HE Triannual Module Instrument

	The table below should only include information for clients who received at least 1 services in the previous 4 month reporting period
	# of New Clients who received service(s) in the reporting period1	# of Clients who received service(s) in the reporting period and received at least one service in the previous year2	Total # of Clients who received service(s) in the reporting period
RWHAP/ Initiative Services
Any RWHAP or Initiative Service	#	#	#
Initiative Services3	#	#	#
Outpatient Ambulatory Health Services4	#	#	#
Medical Case Management Services4	#	#	#
Non-medical Case Management Services4	#	#	#
Mental Health Services4	#	#	#
Substance Abuse Outpatient Care Services4	#	#	#
Substance Abuse Services (Residential) 4	#	#	#
Housing Services4	#	#	#
Health Outcomes
Prescribed ART in the reporting period	#	#	#

¹Any RWHAP client who has not received services from the service provider in the past.

²Any RWHAP client who did received a service from the service provider in the previous calendar year.

³Initiative Services include those services that are funding through Initiative funding but do not meet the definition of a RWHAP service, as outlined in PCN 16-02.

⁴Refer to PCN 16-02 for information on service category definitions.

Public Burden Statement: The purpose of this data collection system is to collect aggregate data on the number of new and existing clients, and clients who have been out of care treated with EHE initiative funding. HAB will use these data to show the impact of the increased funding on reducing new HIV infections, identifying new HIV infections, engaging clients in care and treatment. 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 information collection is 0906-XXXX and it is valid until XX/XX/202X. This information collection is mandatory (through increased Authority under the Public Health Service Act, Section 311(c) (42 USC 243(c)) and title XXVI (42 U.S.C. §§ 300ff-11 et seq.). Public reporting burden for this collection of information is estimated to average 1 hour 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 or [email protected].