0920-21EE 3c_Component 3

Integrated Viral Hepatitis Surveillance and Prevention Funding for Health Departments

Att 3c_Component 3_5-18-2021

OMB: 0920-1353

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Annual Performance Report—Component 3

Integrated Viral Hepatitis Surveillance and Prevention Funding for Health Departments

Component 3: Special Projects—Prevention, Diagnosis, and Treatment Related to the Infectious Disease Consequences of Drug Use


Reporting Agency

Reporting jurisdiction


Contact name (person completing form)


Contact phone number (xxx-xxx-xxxx)


Contact email address


Additional contact name(s) (if applicable)


Additional contact phone number(s)

(xxx-xxx-xxxx)


Additional contact email address(es)


Date of report submission (MM/DD/YYYY)


Reporting Period

(Complete this form with information from Reporting Period selected)

Select one

□ Year 1

□ Year 2

□ Year 3

□ Year 4

□ Year 5



Was Component 3 funded?

Select one

□ No NOTE: Stop here if not funded


□ Yes

-----------------------------------------------------------------------------------------------------------------------------------------------------


3.1—Improve access to services for people who inject drugs (PWID)

in settings disproportionately affected by drug use


Measures 3.1.1.a – 3.1.1.b

  • Number of PWID served, by setting serving PWID (syringe services programs, substance use disorder treatment programs, correctional facilities, emergency departments, hospital-based programs, sexually transmitted disease clinics, homeless services, health centers, other)

  • Syringes distributed, by setting serving PWID



During this reporting period, number of:

Setting serving PWID


Clients served

PWID served

Syringes distributed

Setting 1

Type: >

If other, specify:

>

Name: >

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

Setting 2

Type: >

If other, specify:

>

Name: >

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

Setting 3

Type: >

If other, specify:

>

Name: >

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

Setting 4

Type: >

If other, specify:

>

Name: >

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

Setting 5

Type: >

If other, specify:

>

Name: >

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

Setting 6

Type: >

If other, specify:

>

Name: >

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

Setting 7

Type: >

If other, specify:

>

Name: >

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

Setting 8

Type: >

If other, specify:

>

Name: >

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

Total number of settings:

>

TOTAL: >

TOTAL: >

TOTAL: >




Measures 3.1.2.a – 3.1.2.d

  • Number of PWID who are linked to substance use disorder treatment, by setting serving PWID

  • Number of PWID assessed for opioid use disorder, by setting serving PWID

  • Number of PWID with opioid use disorder, by setting serving PWID

  • Number of PWID with opioid use disorder who are linked to medication for opioid use disorder, by setting serving PWID





During this reporting period, number of:

Setting serving PWID


PWID linked to substance use disorder treatment

PWID assessed for opioid use disorder

PWID with opioid use disorder

PWID with opioid use disorder who were linked to medication for opioid use disorder

Setting 1

Type: >

If other, specify:

>

Name: >

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

Setting 2

Type: >

If other, specify:

>

Name: >

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

Setting 3

Type: >

If other, specify:

>

Name: >

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

Setting 4

Type: >

If other, specify:

>

Name: >

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

Setting 5

Type: >

If other, specify:

>

Name: >

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

Setting 6

Type: >

If other, specify:

>

Name: >

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

Setting 7

Type: >

If other, specify:

>

Name: >

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

Setting 8

Type: >

If other, specify:

>

Name: >

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

Total number of settings:

>

TOTAL: >

TOTAL: >

TOTAL: >

TOTAL: >





Measures 3.1.3.a, 3.1.4.a – 3.1.4.d

  • Number of clients tested for anti-HCV, by setting serving PWID

  • Number of clients testing positive for anti-HCV, by setting serving PWID

  • Number of clients positive for anti-HCV tested for HCV RNA, by setting serving PWID

  • Number of clients testing positive for HCV RNA, by setting serving PWID

  • Number of HCV RNA (+) clients linked to hepatitis C treatment, by setting serving PWID




During this reporting period, number of:

Setting serving PWID


Clients tested for anti-HCV

Clients testing positive for anti-HCV

Clients positive for anti-HCV tested for HCV RNA

Clients testing positive for HCV RNA

HCV RNA (+) clients linked to hepatitis C treatment

Setting 1

Type: >

If other, specify:

>

Name: >

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

Setting 2

Type: >

If other, specify:

>

Name: >

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

Setting 3

Type: >

If other, specify:

>

Name: >

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

Setting 4

Type: >

If other, specify:

>

Name: >

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

Setting 5

Type: >

If other, specify:

>

Name: >

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

Setting 6

Type: >

If other, specify:

>

Name: >

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

Setting 7

Type: >

If other, specify:

>

Name: >

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

Setting 8

Type: >

If other, specify:

>

Name: >

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

Total number of settings:

>

TOTAL: >

TOTAL: >

TOTAL: >

TOTAL: >

TOTAL: >







Measures 3.1.3.b, 3.1.4.e – 3.1.4.f

  • Number of clients screened (anti-HBc, HBsAg, anti-HBs) for HBV, by setting serving PWID

  • Number of clients testing positive for HBsAg, by setting serving PWID

  • Number of HBV (+) clients linked to hepatitis B care, by setting serving PWID



During this reporting period, number of:

Setting serving PWID


Clients screened for HBV (anti-HBc, HBsAg, anti-HBs)

Clients testing positive for HBsAg

HBV (+) clients linked to hepatitis B care

Setting 1

Type: >

If other, specify:

>

Name: >

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

Setting 2

Type: >

If other, specify:

>

Name: >

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

Setting 3

Type: >

If other, specify:

>

Name: >

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

Setting 4

Type: >

If other, specify:

>

Name: >

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

Setting 5

Type: >

If other, specify:

>

Name: >

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

Setting 6

Type: >

If other, specify:

>

Name: >

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

Setting 7

Type: >

If other, specify:

>

Name: >

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

Setting 8

Type: >

If other, specify:

>

Name: >

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

Total number of settings:

>

TOTAL: >

TOTAL: >

TOTAL: >






Measures 3.1.3.c, 3.1.4.g – 3.1.4.h

  • Number of clients screened for HIV, by setting serving PWID

  • Number of clients testing positive for HIV, by setting serving PWID

  • Number of HIV (+) clients linked to HIV treatment, by setting serving PWID




During this reporting period, number of:

Setting serving PWID


Clients screened for HIV


Clients testing positive for HIV

HIV (+) clients linked to HIV treatment

Setting 1

Type: >

If other, specify:

>

Name: >

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

Setting 2

Type: >

If other, specify:

>

Name: >

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

Setting 3

Type: >

If other, specify:

>

Name: >

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

Setting 4

Type: >

If other, specify:

>

Name: >

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

Setting 5

Type: >

If other, specify:

>

Name: >

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

Setting 6

Type: >

If other, specify:

>

Name: >

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

Setting 7

Type: >

If other, specify:

>

Name: >

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

Setting 8

Type: >

If other, specify:

>

Name: >

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

Total number of settings:

>

TOTAL: >

TOTAL: >

TOTAL: >



Measure 3.1.4.i

  • Number of clients referred for treatment for bacterial or fungal infections, by setting serving PWID




During this reporting period, number of:

Setting serving PWID

Clients treated or referred for treatment of bacterial or fungal infections

Setting 1

Type: >

If other, specify:

>

Name: >

>

□ Unknown

□ N/A

Setting 2

Type: >

If other, specify:

>

Name: >

>

□ Unknown

□ N/A

Setting 3

Type: >

If other, specify:

>

Name: >

>

□ Unknown

□ N/A

Setting 4

Type: >

If other, specify:

>

Name: >

>

□ Unknown

□ N/A

Setting 5

Type: >

If other, specify:

>

Name: >

>

□ Unknown

□ N/A

Setting 6

Type: >

If other, specify:

>

Name: >

>

□ Unknown

□ N/A

Setting 7

Type: >

If other, specify:

>

Name: >

>

□ Unknown

□ N/A

Setting 8

Type: >

If other, specify:

>

Name: >

>

□ Unknown

□ N/A

Total number of settings:

>

TOTAL: >


Measures 3.1.5.a – 3.1.5.d

  • Number of hepatitis A vaccination doses administered to clients, by setting serving PWID

  • Number of clients who completed hepatitis A vaccination series, by setting serving PWID

  • Number of hepatitis B vaccination doses administered to clients, by setting serving PWID

  • Number of clients who completed hepatitis B vaccination series, by setting serving PWID



During this reporting period, number of:

Setting serving PWID


Hepatitis A vaccination doses administered

Clients who completed hepatitis A vaccination series

Hepatitis B vaccination doses administered

Clients who completed hepatitis B vaccination series

Setting 1

Type: >

If other, specify:

>

Name: >

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

Setting 2

Type: >

If other, specify:

>

Name: >

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

Setting 3

Type: >

If other, specify:

>

Name: >

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

Setting 4

Type: >

If other, specify:

>

Name: >

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

Setting 5

Type: >

If other, specify:

>

Name: >

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

Setting 6

Type: >

If other, specify:

>

Name: >

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

Setting 7

Type: >

If other, specify:

>

Name: >

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

Setting 8

Type: >

If other, specify:

>

Name: >

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

Total number of settings:

>

TOTAL: >

TOTAL: >

TOTAL: >

TOTAL: >



Measures 3.1.6.a – 3.1.6.c, 3.1.7.a

  • Number of new confirmed acute hepatitis B cases reported among PWID in the jurisdiction

  • Number of new confirmed acute hepatitis C cases reported among PWID in the jurisdiction

  • Number of new confirmed HIV cases reported among PWID in the jurisdiction

  • Jurisdiction reports data on hepatitis C continuum of care for PWID in the jurisdiction, consistent with CDC guidance


How many new confirmed acute hepatitis B cases were reported among people reporting a history of injection drug use in your jurisdiction during this reporting period?

>

□ Unknown

How many new confirmed acute hepatitis C cases were reported among people reporting a history of injection drug use in your jurisdiction during this reporting period?

>

□ Unknown

How many new confirmed HIV cases were reported among people reporting a history of injection drug use in your jurisdiction during this reporting period?

>

□ Unknown

Do you report hepatitis C viral clearance cascade data for reported cases among people reporting a history of injection drug use in your jurisdiction?

Select one

□ Yes

□ No




Use this space if needed

to provide additional information related to Component 3








































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File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorCooley, Laura A. (CDC/DDID/NCHHSTP/DVH)
File Modified0000-00-00
File Created2021-12-13

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