Cluster Close-out Form

National HIV Surveillance System (NHSS)

Attachment 3(g)
Cluster Close-Out Form

Form Approved
OMB No. 0920-0573
Expiration Date:11/30/2022
Cluster Report: Cluster Annual/Closeout Report (Complete for all clusters, regardless of method of detection)
Reporting Jurisdiction Name:
Person Completing Report:

0

2. Local Cluster ID entered into eHARS 
A local cluster ID must be populated on this form and in eHARS.
For molecular clusters, please use the following nomenclature: the twoletter jurisdiction abbreviation followed by the year and month in which
the cluster was first identified and Secure HIV TRACE cluster ID (e.g.,
GA_YYYYMM_10-5)
For time-space clusters, please use the following nomenclature: the two
letter jurisdiction abbreviation followed by the year and month in which
the cluster was first identified and cluster ID with the initials ‘TS’ (e.g.,
GA_YYYYMM_TS789). Please ensure that cluster IDs do NOT contain
personal identifiers.

1. Date form completed:

3. National Cluster ID (if applicable)  

Low morbidity jurisdiction?
Email address:

0

4. Are response activities for this cluster
currently ongoing?

5. Date cluster investigation and response activities closed: (complete only
if the answer to #4 is 'no')
Transmission cluster (within your jurisdiction):**

6. Size of cluster at closeout/current cluster size
Risk network (persons not known to be HIV-infected residing in your
jurisdiction):**
7. Reason(s) for closeout (describe): (complete only if the answer to #4 is 'no')
8. Since the time of cluster detection, were any of the following investigation and/or intervention activities conducted:
8a. Partner Services interviews for persons
in the transmission cluster who were not
previously interviewed?

8b. Partner Services re-interviews for persons in the transmission cluster
who were previously interviewed?

8c. Social network interviews and/or
testing?

8d. Second-generation interviews (interviews of partners of partners)?

8e. Targeted testing events?

8f. Medical chart reviews?

8g. Qualitative interviews?
8h. Messaging activities? (If yes, please
describe using the box to the right)
8g. Other activities (If yes, please describe
using the box to the right)
9a*. How many persons in your
jurisdiction did not have evidence of viral
suppression at the time of identification as
part of the cluster?**
10a^.How many persons in your
jurisdiction were HIV-negative or had
unknown HIV status at the time of
identification as part of the risk
network?**

9b*. Among persons who did not have evidence of viral suppression at the
time of identification as part of the cluster (9a), how many achieved viral
suppression within six months?**
10b^. Of persons who were HIV-negative or had unknown HIV status at the
time of identification as part of the risk network (10a), how many were
tested/re-tested within 6 months?**

10c^. Of persons who were HIV-negative or had unknown HIV status at the
time of identification as part of the risk network (10a), how many were
tested/re-tested at greater than 6 months?**
11^. Results of testing and re-testing for persons in 10a:
(Report only numeric data for each category below.)
11a. No. New Positive1:
11b. Acute: (subset of 11a)
11c. Recent (not acute): (subset of 11a)
11d. No. Negative:
11e. Referred for PrEP: (subset of 11d)
11f. No. Tested but result Unknown:
1

11g. No. Previous Positive1:  
11h. No. Refused testing:
11i. No. Not Located:
11j. No. Outside Jurisdiction:
11k. No. Not tested because person was deceased:
11l. No. not tested for other reason:

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

12a. How many persons in your
jurisdiction were HIV-negative and not on
PrEP at the time of identification as part of
the risk network?**

12b. Of all persons who were HIV-negative and not on PrEP at the time of
identification as part of the risk network (12a), how many were screened
for PrEP within 6 months?**
12c Of all persons who were screened for PrEP within 6 months(12b), how
many were determined to be eligible?**
12d. Of all persons who were eligible for PrEP within 6 months (12c), how
many were referred?**

13. What key lessons were learned through the course of investigating this cluster?

0

14. Please describe the impact of cluster investigation and response activities on
current health department policies and processes (i.e. whether any enhancements
were made to regular HIV prevention and treatment processes such as provision of
case management services or expansion of PrEP resources, whether
communication within the health department or interactions between local and
state health departments changed, whether the cluster was used to advocate for
policy changes, whether additional resources were required to respond to this
particular cluster, etc.).
15. Briefly describe your current level of concern for this cluster and why ongoing
response is still needed. If the cluster response has been closed, instead describe
how you will continue monitoring the cluster for future growth.
^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 CLUSTER ANNUAL/CLOSEOUT REPORT FORM.

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).