Initial Cluster Report Form

National HIV Surveillance System (NHSS)

Attachment 3f.
Initial Cluster Report Form

Form Approved
OMB No. 0920-0573
Expiration Date: XX/XX/XXXX
Cluster Report: Initial Cluster Report
General Cluster Information
Jurisdiction Name:

Low morbidity jurisdiction?

Person Completing Report:

Email address:

1. Date cluster first detected

2. Date form completed

3. Local Cluster ID entered into eHARS

4. National Cluster ID (if applicable)

5. Initial cluster detection method that identified this cluster (please select one; if
'other' is selected, use the box to the right to describe):
6. For clusters identified through molecular analysis, does this cluster meet national priority cluster criteria? (for cluster
defined at 0.5% genetic distance threshold ≥5 diagnoses in past 12 months, or ≥3 diagnoses in past 12 months for lowmorbidity jurisdictions)
7. Had this cluster been identified by any other method?
(If yes, please describe the method(s) and date(s) of prior detection, and note
other cluster IDs for previously identified clusters using the cell to the right)
8. Please indicate which data have been reviewed for persons identified in the cluster:
HIV Partner Services data:

STD Partner Services data:

HIV Partner Services notes:

STD Partner Services notes:

HIV surveillance data:

STD surveillance data:

Viral hepatitis surveillance data:

Ryan White HIV/AIDS Program (including
ADAP):
Discussions with DIS who interviewed
cases:

Social network sites:
Data from other jurisdictions :

Other (specify):

Non-Molecular Clusters. Complete this section only for clusters detected through other methods (i.e. time-space analysis or provider notification).
9. Please describe the characteristics of the cluster that have raised concern (i.e. an
increase in diagnoses over a baseline, an increase in IDU-associated HIV-infections,
etc.).
10. What is your current level of concern for this cluster?
(Note: Select 'High' if additional response is needed, 'Medium' if additional information about the cluster is needed, or 'Low' if no additional investigation activities are
needed at this time. It is not necessary to report clusters of low priority to the CDC unless the cluster meets national priority cluster criteria, or if enhanced response
activities have been initiated)
11. Please briefly describe data review and investigation/response activities
conducted to date for this cluster, and any notable findings.
END OF INITIAL REPORT FORM FOR NON-MOLECULAR CLUSTERS
Molecular Clusters: Existing Data Review. Complete this section only for clusters identified through analysis of HIV sequence data.
12. Number of HIV-positive persons in the molecular cluster at time of detection
who have a report of HIV in your jurisdiction:

Overall number:
Number diagnosed in 12 months prior to
detection:

13. If additional HIV-positive persons with a report of HIV in your jurisdiction have Overall number:
been added to the molecular cluster (based on any subsequent data analysis) since
Number diagnosed in past 12 months:
first identification, enter current numbers:
14. At what genetic distance threshold(s) is this cluster defined? (If 'other' is
selected, use the box to the right to describe)
15. What is the time period of HIV diagnoses used to identify this cluster? (If 'other'
is selected, use the box to the right to describe)
16. How many HIV-positive persons in the molecular cluster as reported in question
Number interviewed:
12 had been interviewed by partner services prior to cluster detection?
17. How many HIV-positive persons in the molecular cluster reported in question
12 were identified as connected to at least one other HIV-positive person in the
Number connected:
molecular cluster through existing partner services data?
18^. Results of HIV testing of named partners of HIV-positive persons in the molecular cluster:

(Include partners residing in your jurisdiction; Do not include molecular cases in the cluster even if they were named partners too. Report only numeric data for each
category below.)
18a. No. New Positive1:
18g. No. Previous Positive1:
18b. Acute: (subset of 18a)
18h. No. Refused testing:
18c. Recent (not acute): (subset of 18a)
18i. No. Not Located:
18d. No. Negative:
18j. No. Outside Jurisdiction:
18k. No. Not tested because person was
18e. Referred for PrEP: (subset of 18d)
deceased:
18f. No. Tested but result Unknown:
18l. No. not tested for other reason:
1

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

19a. Number named partners residing in
your jursidiction: (autopopulated from
#18)
19. How many additional persons have been claimed as partners (excluding other 19b. Number named partners residing
molecular members of the cluster) through DIS interview conducted prior to cluster outside your jursidiction: (autopopulated
detection?
from #18)
19c. Number marginal partners:
19d. Number anonymous partners:
20. Size of transmission cluster in your jurisdiction as identified through review of Transmission cluster size identified
available data (Should equal the overall number in question 13, plus the number of through available data: (autopopulated
new and previous positives reported in question 18a and 18g)
from #18)
21*. How many HIV-positive persons in the transmission cluster reported in
question 20 have evidence of recent viral suppression (most recent viral load <200 Evidence of recent viral suppression:
cp/mL with specimen collection date in the past 12 months)?
22. Number of persons in the risk network in your jurisdiction identified through
review of available data who are not known to be HIV infected (should equal the Risk network size (HIV-negative and HIVnumber of partners with a negative HIV test [18d], those tested but with an
unknown) identified through available
unknown result [18f], or those with an unknown HIV status who were not tested data: (autopopulated from #18)
for any reason [18h, 18i, and 18l])
23. If the transmission cluster or risk network includes persons outside of your
jurisdiction, please describe any collaboration efforts with the other jurisdictions
involved.
Existing Data Review: Cluster-level characteristics, commonalities, and summary
24. Were any common venues or phyical sites identified?
(If yes, describe using the box to the right)
25. Were any common virtual sites identified?
(If yes, describe using the box to the right)
26. What other factors identified might be associated with increased transmission
in this cluster?

0

0

0

0

Key findings from review of partner services, surveillance, and other available data
27. Please provide a brief, narrative summary of key findings based on existing data
review.
28. Based on your initial review of the data, what is your level of concern for this
cluster? (Provide comments regarding your level of concern in the box to the right.)
Note: Select 'High' if additional response is needed, 'Medium' if additional
information about the cluster is needed, or 'Low' if no additional investigation
activities are needed at this time.
^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.
END OF INITIAL REPORT FORM FOR MOLECULAR CLUSTERS

Public reporting burden of this collection of information is estimated to average 60 minutes per response, including the time for
reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing
the collection of information. 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. 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).