Form Approved
OMB No. 0920-New
Expiration Date: XX/XX/XXXX
Using Real-time Prescription and Insurance Claims Data to Support the HIV Care Continuum
Attachment 4
Virginia Care Marker data abstraction
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 Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; Attn: OMB-PRA (0920-New)
Virginia Care Marker data abstraction
First Name*
Last Name*
Social Security Number*
Residence Street Address*
Residence Zip Code*
Residence County*
Residence County Code*
Residence State*
Residence Street address at time of HIV diagnosis*
Residence County at time of HIV diagnosis*
Residence County FIPS code at time of HIV diagnosis*
Residence State at time of HIV diagnosis*
Residence Zip code at HIV disease diagnosis*
Birth Date*, ** (only month and year will be sent to CDC)
Sex *, **
Gender identity**
Race*, **
Ethnicity*, **
Vital Status*, **
Date of Death*, ** (only month and year will be sent to CDC)
ADAP Prescription Prescribed Date *, **
ADAP National Drug Code *, **
ADAP New or Refill Indicator *, **
ADAP Mail-Order Indicator *, **
ADAP Prescription Fill Date *, **
ADAP Quantity of Service *, **
ADAP Days Supply *, **
Date of last use of antiretroviral medications*, **
Date of last Direct ADAP prescription fill*, **
Viral load test result *, **
Date of viral load test result*, **
Care visit date*, **
Provider associated with date of last antiretroviral medication prescription*
Most recent ADAP provider*
HIV disease diagnosis date**
Transmission risk factor**
History of AIDS**
Years since HIV diagnosis**
Prior receipt of Ryan White core or support services**
* indicates data variables that will be used to match individuals within the Medicaid database and Virginia Care Marker databases or to conduct study activities (e.g., identify and contact potential participants, determine study outcomes)
** indicates data variables that will be sent to CDC
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Kathy Byrd |
| File Modified | 0000-00-00 |
| File Created | 2021-10-20 |