Cluster Follow-up Form

National HIV Surveillance System (NHSS)

Attachment 3g.
Cluster Follow-Up Form

Form Approved
OMB No. 0920-0573
Expiration Date: XX/XX/XXXX
Cluster Report: Follow Up 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

0

4. Are response activities for this cluster currently ongoing?
(If no, DO NOT fill out this form. Complete the Annual/Cluster Closeout Report instead).
5*. Current number of persons in the transmission cluster in your jurisdiction:**
6. Current number of persons in the risk network in your jurisdiction who are not known to be HIV positive:**
7. Has testing or re-testing been conducted for any persons who were not know to be HIV positive at the time of
identification as part of the risk network?** (If "yes", please update question 8 below.)
8a. Total number of persons in the risk
network in your jurisdiction tested/retested to date:**
8b. Total number of persons in the risk
8^. Of persons who were HIV-negative or had unknown HIV status at the time of
network in your jurisdiction who newly
identification as part of the risk network, what are the results of testing or retested positive as a result of testing/retesting efforts to date?**
testing efforts:**
8c. Total number of persons in the risk
network in your jurisdiction newly
referred for PrEP:**
9. Please describe any challenges you have encountered in promoting viral
suppression among persons in the transmission cluster, or in conducting testing/retesting and PrEP referral among persons in the risk network:**
10. Since the time of cluster detection, have any of the following investigation and/or intervention activities been conducted:
10a. Partner Services interviews for
10b. Partner Services re-interviews for
persons in the transmission cluster who
persons in the transmission cluster who
were not previously interviewed?
were previously interviewed?
10c. Social network interviews and/or
10d. Second-generation interviews
testing?
(interviews of partners of partners)?
10e. Targeted testing events?
10f. Medical chart reviews?
10g. Qualitative interviews?
10h. Messaging activities? (If yes, please
describe using the box to the right)
10g. Other activities (If yes, please
describe using the box to the right)
11. What is your current level of concern for this cluster?
(Provide comments regarding your current 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.
12. Additional comments:
^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 FOLLOW UP REPORT FORM. If cluster investigation activities are not currently ongoing, please complete the Cluster Closeout Form.

Public reporting burden of this collection of information is estimated to average 30 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).