0920-1353 Component 3: Special Projects—Prevention, Diagnosis, and

Annual Performance Report—PS21-2103 Component 3

Integrated Viral Hepatitis Surveillance and Prevention Funding for Health Departments

Form Approved

OMB No. 0920-1353

Expiration Date: 11/30/2024

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 (0920-1353)

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 (5/1/21-9/30/21) □ Year 2 (10/1/21-9/30/22) □ Year 3 (10/1/22-9/30/23) □ Year 4 (10/1/23-9/30/24) □ Year 5 (10/1/24-4/30/26)

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

in settings disproportionately affected by drug use

List all types of settings serving PWID

During the reporting period were component 3 activities conducted at one or more syringe services programs (SSPs)?

□ Yes

□ No

During the reporting period were component 3 activities conducted at one or substance use disorder (SUD) treatment programs (non-hospital based)?

□ Yes

□ No

During the reporting period were component 3 activities conducted at one or hospital-based substance use disorder (SUD) treatment programs?

□ Yes

□ No

During the reporting period were component 3 activities conducted at one or more hospital-based programs (excluding SUD treatment programs which are included separately above)?

□ Yes

□ No

During the reporting period were component 3 activities conducted at one or more health centers (non-hospital based)?

□ Yes

□ No

During the reporting period were component 3 activities conducted at one or more sexually transmitted infections (STI) clinics? 

□ Yes

□ No

During the reporting period were component 3 activities conducted at one or more mobile clinics? 

□ Yes

□ No

During the reporting period were component 3 activities conducted at one or more emergency departments? 

□ Yes

□ No

During the reporting period were component 3 activities conducted at one or more correctional facilities? 

□ Yes

□ No

During the reporting period were component 3 activities conducted at one or more homeless services? 

□ Yes

□ No

During the reporting period were component 3 activities conducted at another type of setting? 

□ Yes, specify: __________________

□ No

Note: If more than one other type of setting, list the first other type here and describe the additional other type(s) individually in the following questions. 

During the reporting period were component 3 activities conducted at a second other type of setting? 

□ Yes, specify: __________________

□ No

Note: If more than two other types of settings, list the second other type here and describe the additional other type(s) individually in the following questions. 

During the reporting period were component 3 activities conducted at a third other type of setting?

□ Yes, specify: __________________

□ No

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

Setting type serving PWID	Type of data submitted for the measures below for this reporting period (Note: individual data preferred if available). Select one:	During this reporting period, number of:
		Clients served	PWID served	Syringe distribution Select one:
SSPs questions will be skipped if not applicable	□ Individual, client-level for all measures □ Encounter level for all measures □ Other (e.g. a mix of individual and encounter level) If “other” please describe:___________	> □ Unknown	> □ Unknown	□ Syringes are distributed and number is known, specify number: _________ □ Syringes are distributed but number not known □ Syringes are not distributed in this setting
SUD treatment programs, non-hospital-based questions will be skipped if not applicable	□ Individual, client-level for all measures □ Encounter level for all measures □ Other (e.g. a mix of individual and encounter level) If “other” please describe:___________	> □ Unknown	> □ Unknown	□ Syringes are distributed and number is known, specify number: _________ □ Syringes are distributed but number not known □ Syringes are not distributed in this setting
SUD treatment programs, hospital-based questions will be skipped if not applicable	□ Individual, client-level for all measures □ Encounter level for all measures □ Other (e.g. a mix of individual and encounter level) If “other” please describe:___________	> □ Unknown	> □ Unknown	□ Syringes are distributed and number is known, specify number: _________ □ Syringes are distributed but number not known □ Syringes are not distributed in this setting
Hospital-based programs (excluding SUD treatment programs which are included separately above) questions will be skipped if not applicable	□ Individual, client-level for all measures □ Encounter level for all measures □ Other (e.g. a mix of individual and encounter level) If “other” please describe:___________	> □ Unknown	> □ Unknown	□ Syringes are distributed and number is known, specify number: _________ □ Syringes are distributed but number not known □ Syringes are not distributed in this setting
Health centers (non-hospital based) questions will be skipped if not applicable	□ Individual, client-level for all measures □ Encounter level for all measures □ Other (e.g. a mix of individual and encounter level) If “other” please describe:___________	> □ Unknown	> □ Unknown	□ Syringes are distributed and number is known, specify number: _________ □ Syringes are distributed but number not known □ Syringes are not distributed in this setting
STI clinics questions will be skipped if not applicable	□ Individual, client-level for all measures □ Encounter level for all measures □ Other (e.g. a mix of individual and encounter level) If “other” please describe:___________	> □ Unknown	> □ Unknown	□ Syringes are distributed and number is known, specify number: _________ □ Syringes are distributed but number not known □ Syringes are not distributed in this setting
Mobile clinics questions will be skipped if not applicable	□ Individual, client-level for all measures □ Encounter level for all measures □ Other (e.g. a mix of individual and encounter level) If “other” please describe:___________	> □ Unknown	> □ Unknown	□ Syringes are distributed and number is known, specify number: _________ □ Syringes are distributed but number not known □ Syringes are not distributed in this setting
Emergency departments questions will be skipped if not applicable	□ Individual, client-level for all measures □ Encounter level for all measures □ Other (e.g. a mix of individual and encounter level) If “other” please describe:___________	> □ Unknown	> □ Unknown	□ Syringes are distributed and number is known, specify number: _________ □ Syringes are distributed but number not known □ Syringes are not distributed in this setting
Correctional facilities questions will be skipped if not applicable	□ Individual, client-level for all measures □ Encounter level for all measures □ Other (e.g. a mix of individual and encounter level) If “other” please describe:___________	> □ Unknown	> □ Unknown	□ Syringes are distributed and number is known, specify number: _________ □ Syringes are distributed but number not known □ Syringes are not distributed in this setting
Homeless services questions will be skipped if not applicable	□ Individual, client-level for all measures □ Encounter level for all measures □ Other (e.g. a mix of individual and encounter level) If “other” please describe:___________	> □ Unknown	> □ Unknown	□ Syringes are distributed and number is known, specify number: _________ □ Syringes are distributed but number not known □ Syringes are not distributed in this setting
Other type of setting described above, first questions will be skipped if not applicable	□ Individual, client-level for all measures □ Encounter level for all measures □ Other (e.g. a mix of individual and encounter level) If “other” please describe:___________	> □ Unknown	> □ Unknown	□ Syringes are distributed and number is known, specify number: _________ □ Syringes are distributed but number not known □ Syringes are not distributed in this setting
Other type of setting described above, second questions will be skipped if not applicable	□ Individual, client-level for all measures □ Encounter level for all measures □ Other (e.g. a mix of individual and encounter level) If “other” please describe:___________	> □ Unknown	> □ Unknown	□ Syringes are distributed and number is known, specify number: _________ □ Syringes are distributed but number not known □ Syringes are not distributed in this setting
Other type of setting described above, third questions will be skipped if not applicable	□ Individual, client-level for all measures □ Encounter level for all measures □ Other (e.g. a mix of individual and encounter level) If “other” please describe:___________	> □ Unknown	> □ Unknown	□ Syringes are distributed and number is known, specify number: _________ □ Syringes are distributed but number not known □ Syringes are not distributed in this setting

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

Setting serving PWID

Were any of these services offered at any locations for this setting?

Select one:

Type of data submitted for the measures below for this reporting period (Note: individual, client-level data preferred if available).

Select one:

During this reporting period, number of:

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

SSPs

questions will be skipped if not applicable

□ Yes, all services were offered

□ Yes, some but not all services were offered. Please describe specific services offered:__________________

□ No (If no, all remaining columns will be skipped)

□ Individual, client-level for all measures

□ Encounter level for all measures

□ Other (e.g. a mix of individual and encounter level) If “other” please describe:___________

>

□ Unknown

>

□ Unknown

>

□ Unknown

>

□ Unknown

SUD treatment programs, non-hospital-based

questions will be skipped if not applicable

□ Yes, all services were offered

□ Yes, some but not all services were offered. Please describe specific services offered:__________________

□ No (If no, all remaining columns will be skipped)

□ Individual, client-level for all measures

□ Encounter level for all measures

□ Other (e.g. a mix of individual and encounter level) If “other” please describe:___________

>

□ Unknown

>

□ Unknown

>

□ Unknown

>

□ Unknown

SUD treatment programs, hospital-based

questions will be skipped if not applicable

□ Yes, all services were offered

□ Yes, some but not all services were offered. Please describe specific services offered:__________________

□ No (If no, all remaining columns will be skipped)

□ Individual, client-level for all measures

□ Encounter level for all measures

□ Other (e.g. a mix of individual and encounter level) If “other” please describe:___________

>

□ Unknown

>

□ Unknown

>

□ Unknown

>

□ Unknown

Hospital-based programs (excluding SUD treatment programs which are included separately above)

questions will be skipped if not applicable

□ Yes, all services were offered

□ Yes, some but not all services were offered. Please describe specific services offered:__________________

□ No (If no, all remaining columns will be skipped)

□ Individual, client-level for all measures

□ Encounter level for all measures

□ Other (e.g. a mix of individual and encounter level) If “other” please describe:___________

>

□ Unknown

>

□ Unknown

>

□ Unknown

>

□ Unknown

Health centers (non-hospital based)

questions will be skipped if not applicable

□ Yes, all services were offered

□ Yes, some but not all services were offered. Please describe specific services offered:__________________

□ No (If no, all remaining columns will be skipped)

□ Individual, client-level for all measures

□ Encounter level for all measures

□ Other (e.g. a mix of individual and encounter level) If “other” please describe:___________

>

□ Unknown

>

□ Unknown

>

□ Unknown

>

□ Unknown

STI clinics

questions will be skipped if not applicable

□ Yes, all services were offered

□ Yes, some but not all services were offered. Please describe specific services offered:__________________

□ No (If no, all remaining columns will be skipped)

□ Individual, client-level for all measures

□ Encounter level for all measures

□ Other (e.g. a mix of individual and encounter level) If “other” please describe:___________

>

□ Unknown

>

□ Unknown

>

□ Unknown

>

□ Unknown

Mobile clinics

questions will be skipped if not applicable

□ Yes, all services were offered

□ Yes, some but not all services were offered. Please describe specific services offered:__________________

□ No (If no, all remaining columns will be skipped)

□ Individual, client-level for all measures

□ Encounter level for all measures

□ Other (e.g. a mix of individual and encounter level) If “other” please describe:___________

>

□ Unknown

>

□ Unknown

>

□ Unknown

>

□ Unknown

Emergency departments

questions will be skipped if not applicable

□ Yes, all services were offered

□ Yes, some but not all services were offered. Please describe specific services offered:__________________

□ No (If no, all remaining columns will be skipped)

□ Individual, client-level for all measures

□ Encounter level for all measures

□ Other (e.g. a mix of individual and encounter level) If “other” please describe:___________

>

□ Unknown

>

□ Unknown

>

□ Unknown

>

□ Unknown

Correctional facilities

questions will be skipped if not applicable

□ Yes, all services were offered

□ Yes, some but not all services were offered. Please describe specific services offered:__________________

□ No (If no, all remaining columns will be skipped)

□ Individual, client-level for all measures

□ Encounter level for all measures

□ Other (e.g. a mix of individual and encounter level) If “other” please describe:___________

>

□ Unknown

>

□ Unknown

>

□ Unknown

>

□ Unknown

Homeless services

questions will be skipped if not applicable

□ Yes, all services were offered

□ Yes, some but not all services were offered. Please describe specific services offered:__________________

□ No (If no, all remaining columns will be skipped)

□ Individual, client-level for all measures

□ Encounter level for all measures

□ Other (e.g. a mix of individual and encounter level) If “other” please describe:___________

>

□ Unknown

>

□ Unknown

>

□ Unknown

>

□ Unknown

Other type of setting described above, first

questions will be skipped if not applicable

□ Yes, all services were offered

□ Yes, some but not all services were offered. Please describe specific services offered:__________________

□ No (If no, all remaining columns will be skipped)

□ Individual, client-level for all measures

□ Encounter level for all measures

□ Other (e.g. a mix of individual and encounter level) If “other” please describe:___________

>

□ Unknown

>

□ Unknown

>

□ Unknown

>

□ Unknown

Other type of setting described above, second

questions will be skipped if not applicable

□ Yes, all services were offered

□ Yes, some but not all services were offered. Please describe specific services offered:__________________

□ No (If no, all remaining columns will be skipped)

□ Individual, client-level for all measures

□ Encounter level for all measures

□ Other (e.g. a mix of individual and encounter level) If “other” please describe:___________

>

□ Unknown

>

□ Unknown

>

□ Unknown

>

□ Unknown

Other type of setting described above, third

questions will be skipped if not applicable

□ Yes, all services were offered

□ Yes, some but not all services were offered. Please describe specific services offered:__________________

□ No (If no, all remaining columns will be skipped)

□ Individual, client-level for all measures

□ Encounter level for all measures

□ Other (e.g. a mix of individual and encounter level) If “other” please describe:___________

> □ Unknown

> □ Unknown □ N/A

> □ Unknown □ N/A

> □ Unknown □ N/A

> □ Unknown

> □ Unknown □ N/A

> □ Unknown □ N/A

> □ Unknown □ N/A

> □ Unknown

> □ Unknown □ N/A

> □ Unknown □ N/A

> □ Unknown □ N/A

> □ Unknown

> □ Unknown □ N/A

> □ Unknown □ N/A

> □ Unknown □ N/A

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

Setting serving PWID

Were any of these services offered at any locations of this setting?

Select one:

Type of data submitted for the measures below for this reporting period (Note: individual, client-level data preferred if available).

Select one:

During this reporting period, number of:

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

SSPs

questions will be skipped if not applicable

□ Yes, all services were offered

□ Yes, some but not all services were offered. Please describe specific services offered:__________________

□ No (If no, all remaining columns will be skipped)

□ Individual, client-level for all measures

□ Encounter level for all measures

□ Other (e.g. a mix of individual and encounter level) If “other” please describe:___________

>

□ Unknown

>

□ Unknown

>

□ Unknown

>

□ Unknown

>

□ Unknown

SUD treatment programs, non-hospital-based

questions will be skipped if not applicable

□ Yes, all services were offered

□ Yes, some but not all services were offered. Please describe specific services offered:__________________

□ No (If no, all remaining columns will be skipped)

□ Individual, client-level for all measures

□ Encounter level for all measures

□ Other (e.g. a mix of individual and encounter level) If “other” please describe:___________

>

□ Unknown

>

□ Unknown

>

□ Unknown

>

□ Unknown

>

□ Unknown

SUD treatment programs, hospital-based

questions will be skipped if not applicable

□ Yes, all services were offered

□ Yes, some but not all services were offered. Please describe specific services offered:__________________

□ No (If no, all remaining columns will be skipped)

□ Individual, client-level for all measures

□ Encounter level for all measures

□ Other (e.g. a mix of individual and encounter level) If “other” please describe:___________

>

□ Unknown

>

□ Unknown

>

□ Unknown

>

□ Unknown

>

□ Unknown

Hospital-based programs (excluding SUD treatment programs which are included separately above)

questions will be skipped if not applicable

□ Yes, all services were offered

□ Yes, some but not all services were offered. Please describe specific services offered:__________________

□ No (If no, all remaining columns will be skipped)

□ Individual, client-level for all measures

□ Encounter level for all measures

□ Other (e.g. a mix of individual and encounter level) If “other” please describe:___________

>

□ Unknown

>

□ Unknown

>

□ Unknown

>

□ Unknown

>

□ Unknown

Health centers (non-hospital based)

questions will be skipped if not applicable

□ Yes, all services were offered

□ Yes, some but not all services were offered. Please describe specific services offered:__________________

□ No (If no, all remaining columns will be skipped)

□ Individual, client-level for all measures

□ Encounter level for all measures

□ Other (e.g. a mix of individual and encounter level) If “other” please describe:___________

>

□ Unknown

>

□ Unknown

>

□ Unknown

>

□ Unknown

>

□ Unknown

STI clinics

questions will be skipped if not applicable

□ Yes, all services were offered

□ Yes, some but not all services were offered. Please describe specific services offered:__________________

□ No (If no, all remaining columns will be skipped)

□ Individual, client-level for all measures

□ Encounter level for all measures

□ Other (e.g. a mix of individual and encounter level) If “other” please describe:___________

>

□ Unknown

>

□ Unknown

>

□ Unknown

>

□ Unknown

>

□ Unknown

Mobile clinics

questions will be skipped if not applicable

□ Yes, all services were offered

□ Yes, some but not all services were offered. Please describe specific services offered:__________________

□ No (If no, all remaining columns will be skipped)

□ Individual, client-level for all measures

□ Encounter level for all measures

□ Other (e.g. a mix of individual and encounter level) If “other” please describe:___________

>

□ Unknown

>

□ Unknown

>

□ Unknown

>

□ Unknown

>

□ Unknown

Emergency departments

questions will be skipped if not applicable

□ Yes, all services were offered

□ Yes, some but not all services were offered. Please describe specific services offered:__________________

□ No (If no, all remaining columns will be skipped)

□ Individual, client-level for all measures

□ Encounter level for all measures

□ Other (e.g. a mix of individual and encounter level) If “other” please describe:___________

>

□ Unknown

>

□ Unknown

>

□ Unknown

>

□ Unknown

>

□ Unknown

Correctional facilities

questions will be skipped if not applicable

□ Yes, all services were offered

□ Yes, some but not all services were offered. Please describe specific services offered:__________________

□ No (If no, all remaining columns will be skipped)

□ Individual, client-level for all measures

□ Encounter level for all measures

□ Other (e.g. a mix of individual and encounter level) If “other” please describe:___________

>

□ Unknown

>

□ Unknown

>

□ Unknown

>

□ Unknown

>

□ Unknown

Homeless services

questions will be skipped if not applicable

□ Yes, all services were offered

□ Yes, some but not all services were offered. Please describe specific services offered:__________________

□ No (If no, all remaining columns will be skipped)

□ Individual, client-level for all measures

□ Encounter level for all measures

□ Other (e.g. a mix of individual and encounter level) If “other” please describe:___________

>

□ Unknown

>

□ Unknown

>

□ Unknown

>

□ Unknown

>

□ Unknown

Other type of setting described above, first

questions will be skipped if not applicable

□ Yes, all services were offered

□ Yes, some but not all services were offered. Please describe specific services offered:__________________

□ No (If no, all remaining columns will be skipped)

□ Individual, client-level for all measures

□ Encounter level for all measures

□ Other (e.g. a mix of individual and encounter level) If “other” please describe:___________

>

□ Unknown

>

□ Unknown

>

□ Unknown

>

□ Unknown

>

□ Unknown

Other type of setting described above, second

questions will be skipped if not applicable

□ Yes, all services were offered

□ Yes, some but not all services were offered. Please describe specific services offered:__________________

□ No (If no, all remaining columns will be skipped)

□ Individual, client-level for all measures

□ Encounter level for all measures

□ Other (e.g. a mix of individual and encounter level) If “other” please describe:___________

>

□ Unknown

>

□ Unknown

>

□ Unknown

>

□ Unknown

>

□ Unknown

Other type of setting described above, third

questions will be skipped if not applicable

□ Yes, all services were offered

□ Yes, some but not all services were offered. Please describe specific services offered:__________________

□ No (If no, all remaining columns will be skipped)

□ Individual, client-level for all measures

□ Encounter level for all measures

□ Other (e.g. a mix of individual and encounter level) If “other” please describe:___________

> □ Unknown

> □ Unknown □ N/A

> □ Unknown □ N/A

> □ Unknown □ N/A

> □ Unknown

> □ Unknown □ N/A

> □ Unknown □ N/A

> □ Unknown □ N/A

> □ Unknown

> □ Unknown □ N/A

> □ Unknown □ N/A

> □ Unknown □ N/A

> □ Unknown

> □ Unknown □ N/A

> □ Unknown □ N/A

> □ Unknown □ N/A

> □ Unknown

> □ Unknown □ N/A

> □ Unknown □ N/A

> □ Unknown □ N/A

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

Setting serving PWID

Were any of these services offered at any locations of this setting?

Select one:

Type of data submitted for the measures below for this reporting period (Note: individual, client-level data preferred if available).

Select one:

During this reporting period, number of:

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

Clients testing positive for HBsAg

HBV (+) clients linked to hepatitis B care

SSPs

questions will be skipped if not applicable

□ Yes, all services were offered

□ Yes, some but not all services were offered. Please describe specific services offered:__________________

□ No (If no, all remaining columns will be skipped)

□ Individual, client-level for all measures

□ Encounter level for all measures

□ Other (e.g. a mix of individual and encounter level) If “other” please describe:___________

>

□ Unknown

>

□ Unknown

>

□ Unknown

SUD treatment programs, non-hospital-based

questions will be skipped if not applicable

□ Yes, all services were offered

□ Yes, some but not all services were offered. Please describe specific services offered:__________________

□ No (If no, all remaining columns will be skipped)

□ Individual, client-level for all measures

□ Encounter level for all measures

□ Other (e.g. a mix of individual and encounter level) If “other” please describe:___________

>

□ Unknown

>

□ Unknown

>

□ Unknown

SUD treatment programs, hospital-based

questions will be skipped if not applicable

□ Yes, all services were offered

□ Yes, some but not all services were offered. Please describe specific services offered:__________________

□ No (If no, all remaining columns will be skipped)

□ Individual, client-level for all measures

□ Encounter level for all measures

□ Other (e.g. a mix of individual and encounter level) If “other” please describe:___________

>

□ Unknown

>

□ Unknown

>

□ Unknown

Hospital-based programs (excluding SUD treatment programs which are included separately above)

questions will be skipped if not applicable

□ Yes, all services were offered

□ Yes, some but not all services were offered. Please describe specific services offered:__________________

□ No (If no, all remaining columns will be skipped)

□ Individual, client-level for all measures

□ Encounter level for all measures

□ Other (e.g. a mix of individual and encounter level) If “other” please describe:___________

>

□ Unknown

>

□ Unknown

>

□ Unknown

Health centers (non-hospital based)

questions will be skipped if not applicable

□ Yes, all services were offered

□ Yes, some but not all services were offered. Please describe specific services offered:__________________

□ No (If no, all remaining columns will be skipped)

□ Individual, client-level for all measures

□ Encounter level for all measures

□ Other (e.g. a mix of individual and encounter level) If “other” please describe:___________

>

□ Unknown

>

□ Unknown

>

□ Unknown

STI clinics

questions will be skipped if not applicable

□ Yes, all services were offered

□ Yes, some but not all services were offered. Please describe specific services offered:__________________

□ No (If no, all remaining columns will be skipped)

□ Individual, client-level for all measures

□ Encounter level for all measures

□ Other (e.g. a mix of individual and encounter level) If “other” please describe:___________

>

□ Unknown

>

□ Unknown

>

□ Unknown

Mobile clinics

questions will be skipped if not applicable

□ Yes, all services were offered

□ Yes, some but not all services were offered. Please describe specific services offered:__________________

□ No (If no, all remaining columns will be skipped)

□ Individual, client-level for all measures

□ Encounter level for all measures

□ Other (e.g. a mix of individual and encounter level) If “other” please describe:___________

>

□ Unknown

>

□ Unknown

>

□ Unknown

Emergency departments

questions will be skipped if not applicable

□ Yes, all services were offered

□ Yes, some but not all services were offered. Please describe specific services offered:__________________

□ No (If no, all remaining columns will be skipped)

□ Individual, client-level for all measures

□ Encounter level for all measures

□ Other (e.g. a mix of individual and encounter level) If “other” please describe:___________

>

□ Unknown

>

□ Unknown

>

□ Unknown

Correctional facilities

questions will be skipped if not applicable

□ Yes, all services were offered

□ Yes, some but not all services were offered. Please describe specific services offered:__________________

□ No (If no, all remaining columns will be skipped)

□ Individual, client-level for all measures

□ Encounter level for all measures

□ Other (e.g. a mix of individual and encounter level) If “other” please describe:___________

>

□ Unknown

>

□ Unknown

>

□ Unknown

Homeless services

questions will be skipped if not applicable

□ Yes, all services were offered

□ Yes, some but not all services were offered. Please describe specific services offered:__________________

□ No (If no, all remaining columns will be skipped)

□ Individual, client-level for all measures

□ Encounter level for all measures

□ Other (e.g. a mix of individual and encounter level) If “other” please describe:___________

>

□ Unknown

>

□ Unknown

>

□ Unknown

Other type of setting described above, first

questions will be skipped if not applicable

□ Yes, all services were offered

□ Yes, some but not all services were offered. Please describe specific services offered:__________________

□ No (If no, all remaining columns will be skipped)

□ Individual, client-level for all measures

□ Encounter level for all measures

□ Other (e.g. a mix of individual and encounter level) If “other” please describe:___________

>

□ Unknown

>

□ Unknown

>

□ Unknown

Other type of setting described above, second

questions will be skipped if not applicable

□ Yes, all services were offered

□ Yes, some but not all services were offered. Please describe specific services offered:__________________

□ No (If no, all remaining columns will be skipped)

□ Individual, client-level for all measures

□ Encounter level for all measures

□ Other (e.g. a mix of individual and encounter level) If “other” please describe:___________

>

□ Unknown

>

□ Unknown

>

□ Unknown

Other type of setting described above, third

questions will be skipped if not applicable

□ Yes, all services were offered

□ Yes, some but not all services were offered. Please describe specific services offered:__________________

□ No (If no, all remaining columns will be skipped)

□ Individual, client-level for all measures

□ Encounter level for all measures

□ Other (e.g. a mix of individual and encounter level) If “other” please describe:___________

> □ Unknown

> □ Unknown □ N/A

> □ Unknown □ N/A

> □ Unknown □ N/A

> □ Unknown

> □ Unknown □ N/A

> □ Unknown □ N/A

> □ Unknown □ N/A

> □ Unknown

> □ Unknown □ N/A

> □ Unknown □ N/A

> □ Unknown □ N/A

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

Setting serving PWID

Were any of these services offered at any locations of this setting?

Select one:

Type of data submitted for the measures below for this reporting period (Note: individual, client-level data preferred if available).

Select one:

During this reporting period, number of:

Clients screened for HIV

Clients testing positive for HIV

HIV (+) clients linked to HIV treatment

SSPs

questions will be skipped if not applicable

□ Yes, all services were offered

□ Yes, some but not all services were offered. Please describe specific services offered:__________________

□ No (If no, all remaining columns will be skipped)

□ Individual, client-level for all measures

□ Encounter level for all measures

□ Other (e.g. a mix of individual and encounter level) If “other” please describe:___________

>

□ Unknown

>

□ Unknown

>

□ Unknown

SUD treatment programs, non-hospital-based

questions will be skipped if not applicable

□ Yes, all services were offered

□ Yes, some but not all services were offered. Please describe specific services offered:__________________

□ No (If no, all remaining columns will be skipped)

□ Individual, client-level for all measures

□ Encounter level for all measures

□ Other (e.g. a mix of individual and encounter level) If “other” please describe:___________

>

□ Unknown

>

□ Unknown

>

□ Unknown

SUD treatment programs, hospital-based

questions will be skipped if not applicable

□ Yes, all services were offered

□ Yes, some but not all services were offered. Please describe specific services offered:__________________

□ No (If no, all remaining columns will be skipped)

□ Individual, client-level for all measures

□ Encounter level for all measures

□ Other (e.g. a mix of individual and encounter level) If “other” please describe:___________

>

□ Unknown

>

□ Unknown

>

□ Unknown

Hospital-based programs (excluding SUD treatment programs which are included separately above)

questions will be skipped if not applicable

□ Yes, all services were offered

□ Yes, some but not all services were offered. Please describe specific services offered:__________________

□ No (If no, all remaining columns will be skipped)

□ Individual, client-level for all measures

□ Encounter level for all measures

□ Other (e.g. a mix of individual and encounter level) If “other” please describe:___________

>

□ Unknown

>

□ Unknown

>

□ Unknown

Health centers (non-hospital based)

questions will be skipped if not applicable

□ Yes, all services were offered

□ Yes, some but not all services were offered. Please describe specific services offered:__________________

□ No (If no, all remaining columns will be skipped)

□ Individual, client-level for all measures

□ Encounter level for all measures

□ Other (e.g. a mix of individual and encounter level) If “other” please describe:___________

>

□ Unknown

>

□ Unknown

>

□ Unknown

STI clinics

questions will be skipped if not applicable

□ Yes, all services were offered

□ Yes, some but not all services were offered. Please describe specific services offered:__________________

□ No (If no, all remaining columns will be skipped)

□ Individual, client-level for all measures

□ Encounter level for all measures

□ Other (e.g. a mix of individual and encounter level) If “other” please describe:___________

>

□ Unknown

>

□ Unknown

>

□ Unknown

Mobile clinics

questions will be skipped if not applicable

□ Yes, all services were offered

□ Yes, some but not all services were offered. Please describe specific services offered:__________________

□ No (If no, all remaining columns will be skipped)

□ Individual, client-level for all measures

□ Encounter level for all measures

□ Other (e.g. a mix of individual and encounter level) If “other” please describe:___________

>

□ Unknown

>

□ Unknown

>

□ Unknown

Emergency departments

questions will be skipped if not applicable

□ Yes, all services were offered

□ Yes, some but not all services were offered. Please describe specific services offered:__________________

□ No (If no, all remaining columns will be skipped)

□ Individual, client-level for all measures

□ Encounter level for all measures

□ Other (e.g. a mix of individual and encounter level) If “other” please describe:___________

>

□ Unknown

>

□ Unknown

>

□ Unknown

Correctional facilities

questions will be skipped if not applicable

□ Yes, all services were offered

□ Yes, some but not all services were offered. Please describe specific services offered:__________________

□ No (If no, all remaining columns will be skipped)

□ Individual, client-level for all measures

□ Encounter level for all measures

□ Other (e.g. a mix of individual and encounter level) If “other” please describe:___________

>

□ Unknown

>

□ Unknown

>

□ Unknown

Homeless services

questions will be skipped if not applicable

□ Yes, all services were offered

□ Yes, some but not all services were offered. Please describe specific services offered:__________________

□ No (If no, all remaining columns will be skipped)

□ Individual, client-level for all measures

□ Encounter level for all measures

□ Other (e.g. a mix of individual and encounter level) If “other” please describe:___________

>

□ Unknown

>

□ Unknown

>

□ Unknown

Other type of setting described above, first

questions will be skipped if not applicable

□ Yes, all services were offered

□ Yes, some but not all services were offered. Please describe specific services offered:__________________

□ No (If no, all remaining columns will be skipped)

□ Individual, client-level for all measures

□ Encounter level for all measures

□ Other (e.g. a mix of individual and encounter level) If “other” please describe:___________

>

□ Unknown

>

□ Unknown

>

□ Unknown

Other type of setting described above, second

questions will be skipped if not applicable

□ Yes, all services were offered

□ Yes, some but not all services were offered. Please describe specific services offered:__________________

□ No (If no, all remaining columns will be skipped)

□ Individual, client-level for all measures

□ Encounter level for all measures

□ Other (e.g. a mix of individual and encounter level) If “other” please describe:___________

>

□ Unknown

>

□ Unknown

>

□ Unknown

Other type of setting described above, third

questions will be skipped if not applicable

□ Yes, all services were offered

□ Yes, some but not all services were offered. Please describe specific services offered:__________________

□ No (If no, all remaining columns will be skipped)

□ Individual, client-level for all measures

□ Encounter level for all measures

□ Other (e.g. a mix of individual and encounter level) If “other” please describe:___________

> □ Unknown

> □ Unknown □ N/A

> □ Unknown □ N/A

> □ Unknown □ N/A

> □ Unknown

> □ Unknown □ N/A

> □ Unknown □ N/A

> □ Unknown □ N/A

> □ Unknown

> □ Unknown □ N/A

> □ Unknown □ N/A

> □ Unknown □ N/A

Measure 3.1.4.i

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

Setting serving PWID	Were any of these services offered at any locations of this setting? Select one:	Type of data submitted for the measures below for this reporting period (Note: individual, client-level data preferred if available). Select one:	During this reporting period, number of:
			Clients treated or referred for treatment of bacterial or fungal infections
SSPs questions will be skipped if not applicable	□ Yes, all services were offered □ Yes, some but not all services were offered. Please describe specific services offered:__________________ □ No (If no, all remaining columns will be skipped)	□ Individual, client-level for all measures □ Encounter level for all measures □ Other (e.g. a mix of individual and encounter level) If “other” please describe:___________	> □ Unknown
SUD treatment programs, non-hospital-based questions will be skipped if not applicable	□ Yes, all services were offered □ Yes, some but not all services were offered. Please describe specific services offered:__________________ □ No (If no, all remaining columns will be skipped)	□ Individual, client-level for all measures □ Encounter level for all measures □ Other (e.g. a mix of individual and encounter level) If “other” please describe:___________	> □ Unknown
SUD treatment programs, hospital-based questions will be skipped if not applicable	□ Yes, all services were offered □ Yes, some but not all services were offered. Please describe specific services offered:__________________ □ No (If no, all remaining columns will be skipped)	□ Individual, client-level for all measures □ Encounter level for all measures □ Other (e.g. a mix of individual and encounter level) If “other” please describe:___________	> □ Unknown
Hospital-based programs (excluding SUD treatment programs which are included separately above) questions will be skipped if not applicable	□ Yes, all services were offered □ Yes, some but not all services were offered. Please describe specific services offered:__________________ □ No (If no, all remaining columns will be skipped)	□ Individual, client-level for all measures □ Encounter level for all measures □ Other (e.g. a mix of individual and encounter level) If “other” please describe:___________	> □ Unknown
Health centers (non-hospital based) questions will be skipped if not applicable	□ Yes, all services were offered □ Yes, some but not all services were offered. Please describe specific services offered:__________________ □ No (If no, all remaining columns will be skipped)	□ Individual, client-level for all measures □ Encounter level for all measures □ Other (e.g. a mix of individual and encounter level) If “other” please describe:___________	> □ Unknown
STI clinics questions will be skipped if not applicable	□ Yes, all services were offered □ Yes, some but not all services were offered. Please describe specific services offered:__________________ □ No (If no, all remaining columns will be skipped)	□ Individual, client-level for all measures □ Encounter level for all measures □ Other (e.g. a mix of individual and encounter level) If “other” please describe:___________	> □ Unknown
Mobile clinics questions will be skipped if not applicable	□ Yes, all services were offered □ Yes, some but not all services were offered. Please describe specific services offered:__________________ □ No (If no, all remaining columns will be skipped)	□ Individual, client-level for all measures □ Encounter level for all measures □ Other (e.g. a mix of individual and encounter level) If “other” please describe:___________	> □ Unknown
Emergency departments questions will be skipped if not applicable	□ Yes, all services were offered □ Yes, some but not all services were offered. Please describe specific services offered:__________________ □ No (If no, all remaining columns will be skipped)	□ Individual, client-level for all measures □ Encounter level for all measures □ Other (e.g. a mix of individual and encounter level) If “other” please describe:___________	> □ Unknown
Correctional facilities questions will be skipped if not applicable	□ Yes, all services were offered □ Yes, some but not all services were offered. Please describe specific services offered:__________________ □ No (If no, all remaining columns will be skipped)	□ Individual, client-level for all measures □ Encounter level for all measures □ Other (e.g. a mix of individual and encounter level) If “other” please describe:___________	> □ Unknown
Homeless services questions will be skipped if not applicable	□ Yes, all services were offered □ Yes, some but not all services were offered. Please describe specific services offered:__________________ □ No (If no, all remaining columns will be skipped)	□ Individual, client-level for all measures □ Encounter level for all measures □ Other (e.g. a mix of individual and encounter level) If “other” please describe:___________	> □ Unknown
Other type of setting described above, first questions will be skipped if not applicable	□ Yes, all services were offered □ Yes, some but not all services were offered. Please describe specific services offered:__________________ □ No (If no, all remaining columns will be skipped)	□ Individual, client-level for all measures □ Encounter level for all measures □ Other (e.g. a mix of individual and encounter level) If “other” please describe:___________	> □ Unknown
Other type of setting described above, second questions will be skipped if not applicable	□ Yes, all services were offered □ Yes, some but not all services were offered. Please describe specific services offered:__________________ □ No (If no, all remaining columns will be skipped)	□ Individual, client-level for all measures □ Encounter level for all measures □ Other (e.g. a mix of individual and encounter level) If “other” please describe:___________	> □ Unknown
Other type of setting described above, third questions will be skipped if not applicable	□ Yes, all services were offered □ Yes, some but not all services were offered. Please describe specific services offered:__________________ □ No (If no, all remaining columns will be skipped)	□ Individual, client-level for all measures □ Encounter level for all measures □ Other (e.g. a mix of individual and encounter level) If “other” please describe:___________	> □ Unknown

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

Setting serving PWID

Were any of these services offered at any locations of this setting?

Select one:

Type of data submitted for the measures below for this reporting period (Note: individual, client-level data preferred if available).

Select one:

During this reporting period, number of:

Hepatitis A vaccination doses administered

Clients who completed hepatitis A vaccination series

Hepatitis B vaccination doses administered

Clients who completed hepatitis B vaccination series

SSPs

questions will be skipped if not applicable

□ Yes, all services were offered

□ Yes, some but not all services were offered. Please describe specific services offered:__________________

□ No (If no, all remaining columns will be skipped)

□ Individual, client-level for all measures

□ Encounter level for all measures

□ Other (e.g. a mix of individual and encounter level) If “other” please describe:___________

>

□ Unknown

>

□ Unknown

>

□ Unknown

>

□ Unknown

SUD treatment programs, non-hospital-based

questions will be skipped if not applicable

□ Yes, all services were offered

□ Yes, some but not all services were offered. Please describe specific services offered:__________________

□ No (If no, all remaining columns will be skipped)

□ Individual, client-level for all measures

□ Encounter level for all measures

□ Other (e.g. a mix of individual and encounter level) If “other” please describe:___________

>

□ Unknown

>

□ Unknown

>

□ Unknown

>

□ Unknown

SUD treatment programs, hospital-based

questions will be skipped if not applicable

□ Yes, all services were offered

□ Yes, some but not all services were offered. Please describe specific services offered:__________________

□ No (If no, all remaining columns will be skipped)

□ Individual, client-level for all measures

□ Encounter level for all measures

□ Other (e.g. a mix of individual and encounter level) If “other” please describe:___________

>

□ Unknown

>

□ Unknown

>

□ Unknown

>

□ Unknown

Hospital-based programs (excluding SUD treatment programs which are included separately above)

questions will be skipped if not applicable

□ Yes, all services were offered

□ Yes, some but not all services were offered. Please describe specific services offered:__________________

□ No (If no, all remaining columns will be skipped)

□ Individual, client-level for all measures

□ Encounter level for all measures

□ Other (e.g. a mix of individual and encounter level) If “other” please describe:___________

>

□ Unknown

>

□ Unknown

>

□ Unknown

>

□ Unknown

Health centers (non-hospital based)

questions will be skipped if not applicable

□ Yes, all services were offered

□ Yes, some but not all services were offered. Please describe specific services offered:__________________

□ No (If no, all remaining columns will be skipped)

□ Individual, client-level for all measures

□ Encounter level for all measures

□ Other (e.g. a mix of individual and encounter level) If “other” please describe:___________

>

□ Unknown

>

□ Unknown

>

□ Unknown

>

□ Unknown

STI clinics

questions will be skipped if not applicable

□ Yes, all services were offered

□ Yes, some but not all services were offered. Please describe specific services offered:__________________

□ No (If no, all remaining columns will be skipped)

□ Individual, client-level for all measures

□ Encounter level for all measures

□ Other (e.g. a mix of individual and encounter level) If “other” please describe:___________

>

□ Unknown

>

□ Unknown

>

□ Unknown

>

□ Unknown

Mobile clinics

questions will be skipped if not applicable

□ Yes, all services were offered

□ Yes, some but not all services were offered. Please describe specific services offered:__________________

□ No (If no, all remaining columns will be skipped)

□ Individual, client-level for all measures

□ Encounter level for all measures

□ Other (e.g. a mix of individual and encounter level) If “other” please describe:___________

>

□ Unknown

>

□ Unknown

>

□ Unknown

>

□ Unknown

Emergency departments

questions will be skipped if not applicable

□ Yes, all services were offered

□ Yes, some but not all services were offered. Please describe specific services offered:__________________

□ No (If no, all remaining columns will be skipped)

□ Individual, client-level for all measures

□ Encounter level for all measures

□ Other (e.g. a mix of individual and encounter level) If “other” please describe:___________

>

□ Unknown

>

□ Unknown

>

□ Unknown

>

□ Unknown

Correctional facilities

questions will be skipped if not applicable

□ Yes, all services were offered

□ Yes, some but not all services were offered. Please describe specific services offered:__________________

□ No (If no, all remaining columns will be skipped)

□ Individual, client-level for all measures

□ Encounter level for all measures

□ Other (e.g. a mix of individual and encounter level) If “other” please describe:___________

>

□ Unknown

>

□ Unknown

>

□ Unknown

>

□ Unknown

Homeless services

questions will be skipped if not applicable

□ Yes, all services were offered

□ Yes, some but not all services were offered. Please describe specific services offered:__________________

□ No (If no, all remaining columns will be skipped)

□ Individual, client-level for all measures

□ Encounter level for all measures

□ Other (e.g. a mix of individual and encounter level) If “other” please describe:___________

>

□ Unknown

>

□ Unknown

>

□ Unknown

>

□ Unknown

Other type of setting described above, first

questions will be skipped if not applicable

□ Yes, all services were offered

□ Yes, some but not all services were offered. Please describe specific services offered:__________________

□ No (If no, all remaining columns will be skipped)

□ Individual, client-level for all measures

□ Encounter level for all measures

□ Other (e.g. a mix of individual and encounter level) If “other” please describe:___________

>

□ Unknown

>

□ Unknown

>

□ Unknown

>

□ Unknown

Other type of setting described above, second

questions will be skipped if not applicable

□ Yes, all services were offered

□ Yes, some but not all services were offered. Please describe specific services offered:__________________

□ No (If no, all remaining columns will be skipped)

□ Individual, client-level for all measures

□ Encounter level for all measures

□ Other (e.g. a mix of individual and encounter level) If “other” please describe:___________

>

□ Unknown

>

□ Unknown

>

□ Unknown

>

□ Unknown

Other type of setting described above, third

questions will be skipped if not applicable

□ Yes, all services were offered

□ Yes, some but not all services were offered. Please describe specific services offered:__________________

□ No (If no, all remaining columns will be skipped)

□ Individual, client-level for all measures

□ Encounter level for all measures

□ Other (e.g. a mix of individual and encounter level) If “other” please describe:___________

> □ Unknown

> □ Unknown □ N/A

> □ Unknown □ N/A

> □ Unknown □ N/A

> □ Unknown

> □ Unknown □ N/A

> □ Unknown □ N/A

> □ Unknown □ N/A

> □ Unknown

> □ Unknown □ N/A

> □ Unknown □ N/A

> □ Unknown □ N/A

> □ Unknown

> □ Unknown □ N/A

> □ Unknown □ N/A

> □ Unknown □ N/A

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 (with or without co-infection with HIV or other forms of viral hepatitis) 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 (with or without co-infection with HIV or other forms of viral hepatitis) were reported among people reporting a history of injection drug use in your jurisdiction during this reporting period?	> □ Unknown
How many new confirmed HIV (with or without viral hepatitis co-infection) 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

Please use this space to provide information about challenges experienced when implementing Strategy 3.1 activities. Include additional contextual information that would help us interpret your annual performance data. Please include challenges with data collection as well as implementation. For instance, please indicate if data are not collected at an individual client level, or if data for one or more of the measures could not be de-duplicated, meaning that the same individual client may have been included more than once.      Also, if you need technical assistance from CDC, please indicate this in this field.

Please use this space to provide information about successes experienced when implementing Strategy 3.1 activities. Include additional contextual information that would help us interpret your annual performance data. For example, the number of locations associated with each setting type, or other explanatory notation, could be listed here if needed.

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