Form 0920-1282 Enhancing STI and Sexual Health Clinic Infrastructure Da

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Overview

Overview
A-CommEngagement&Partnership
B- Service provision
B- Persons Served
B-STI Diagnosis
B-Partner Svs_STI-HIV Treatment
C-Expanded Access

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Sheet 1: Overview

CoAg Title:	Enhancing STI and Sexual Health Clinic Infrastructure							Form Approved
CoAg Number:	RFA PS23-0011							OMB Control No. 0920-1282
Agency:								Exp. Date: 06/30/2026
Funded for Strategy C?
Reporting Period:
Date completed:
Click a named tab at the bottom of the workbook to jump to the corresponding worksheet.
Instructions:
Please use this template to submit performance measures for ESSHCI Activities. This template will be completed twice a year, within the coag period. Please refer to the performance measures guidance document for additional information and definitions for completing the template. Definitions for some measures are also included in footnotes, annotated by numbers, at the bottom of the respective tables in this reporting template.
If you need assistance or have ANY questions about completing this template, please send an email to your DSTDP project officer.
Notes on Data Entry:
All unshaded cells are available for user input.
Drop-down lists included in the worksheets will be identifiable through a downward arrow that appears when you select it. Gray cells are auto-calculated and do not require data entry. Blacked-out cells are not required and do not require data entry.
ONLY Recipients funded for strategy C are required to complement the strategy C tab. Data for strategies A and B are required for all recipients.
Saving and Submitting Your Work:
Please save this file as "[Agency Name]_Evaluation Report.Period[number]_Date of Submission[mm.dd.yy]"
To submit your report, save and upload a copy of the completed workbook ending in .xls or .xlsx as a Grant Note in GrantSolutions by xxx Please send a courtesy email to your DSTDP project officer to notify them of your submission.
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Public reporting burden of this collection of information is estimated to average 40 hours per response per year, 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 (0920-1282).

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Sheet 2: A-CommEngagement&Partnership

	Community Engagement and Partnerships
	Aggregate Data Tables for PM-1 - 5
	Table A1. For each type of engagement with your community advisory group, please enter the number of times each engagement occurred in this reporting period (PM-1a, PM-1b)
	Type of engagements with community advisory group	Number of engagements with community advisory group	Optional Field
	1Regular, In-person meetings
	2Regular, Virtual meetings
	3Hybrid meetings
	4Listening sessions
	5Surveys
	6Focused discussion groups
	Other (Please specify)		Enter text specifying the type(s) of engagement with the community advisory group
	Table A2. Please provide the total and representative numbers of your community advisory group members (PM-2 & 3)
	Gray cells: Auto-calculated and do not represent a reporting burden
	Total number of community advisory group members
	Number of community advisory group members that identify as belonging to priority population(s) your clinic(s) serves.
	Proportion of community advisory group representing priority population(s) served by the clinic.	% Auto-Calculate
	Please provide a summary of the actionable, community-informed, clinic-level plan developed, with input from the community advisory group, to increase access to quality comprehensive sexual health services in your clinic. The description should include how your clinic involved and incorporated your community advisory group in developing the actionable clinic-level plan.
	Table A3. For each type of community partnership, please enter the number of partners that collaborated on STI prevention with your clinic, in this reporting period (PM-4a, 4b & 5)
	Type of community partners engaging in STI prevention collaboration	Number of community partners engaging in STI prevention collaboration	Optional Field
	STI Clinics
	Clinics (Other)
	Hospitals
	Community-based organizations
	Faith-based organizations
	Academic institutions
	Pharmacies
	Other (Please specify)		Enter text specifying the type(s) of community partner
	Please describe the partnerships and activities conducted to address STIs. Including a description of any assessment(s) conducted and outcomes achieved for the clinic-level plan.
	Please provide details outlining each partner's role in the actionable clinic-level plan.	Name of partner	Level of previous partnership (Select dropdown)	Type of Partner (Select dropdown)	If "Other," please specify.	What role does this partner play? What type of services do they provide?	How will this partner contribute to the clinic-level plan? How will this partnership help your clinic reach/engage priority population(s)?
	Data Quality
	Are there missing/unavailable data for any performance measures in the table(s) above?
	Please explain the issues with the missing data, including variable names, and your plans to enhance the completeness of your data (if applicable).
1	Regular, In-person meetings: Scheduled/standing meetings where most attendees were in-person in one meeting place.
2	Regular, Virtual meetings: Scheduled/standing meetings taking place in a virtual meeting room such as, Zoom, Microsoft Teams, Google meet etc.
3	Hybrid Meetings: Regular meetings hosted simultaneously in an in-person location and a virtual meeting/video-conferencing platform.
4	Listening sessions: Gathering hosted to garner feedback on one or more issues related to the project, whether taking place in-person or virtually.
5	Surveys: questionnaire administered to solicit responses to questions related to the project; either web-based or paper format
6	Focused discussion groups: Gathering hosted for an interactive discussion on a specific topic, related to the project, whether taking place in-person or virtually.

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Sheet 3: B- Service provision

Sexual Health Services and Patient Satisfaction

Aggregate Data Tables for PM-7, 10, 18

Gray cells: Auto-calculated and do not represent a reporting burden

Table B1: Patient Satisfaction with Clinic Services and STI Care. (PM 11) Please enter data summarizing results from the CDC Patient Satisfaction Measures.

Survey Question

0

1

2

3

4

5

Q1: Using a rating of 0 to 5, where 0 is the worst clinical care and 5 is the best clinical care, how would you rate the STI care you received in today’s visit?

N

%

N

%

N

%

N

%

N

%

N

%

Very poor

Poor

Fair

Good

Very Good

Q2: I would describe my overall experience during the clinic visit as:

N

%

N

%

N

%

N

%

N

%

Table B2: Providing Comprehensive Sexual Health Services (PM 7 & 18)

Performance Measure

Data Fields

Please describe the strategies developed to improve clinic systems for referrals, lab systems, linkages to care, treatment, and/or record keeping. Description should include clinical services, laboratory services, staffing strategy, and clinical training plans.

Please describe the formal linkage agreements established with community partners collaborating for sexual health and co-occuring conditions.

Data Quality

Are there missing/unavailable data for any performance measures in the table(s) above?

Please explain the issues with the missing data, including variables names, and your plans to enhance the completeness of your data (if applicable).

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Sheet 4: B- Persons Served

Sexual Health Services- Prevention
Aggregate Data Tables for PM-8 & 9
Black-out cells: Are not required for those measures and do not represent a reporting burden
Table B3. Persons Served and Receiving Biomedical HIV and STI Prevention Services
		Number of Unique Persons Served1	Number of Persons Who Received HIV PrEP2	Number of Persons Who Received HIV nPEP3	Number of Persons Who Received Doxy PEP for Bacterial STIs4
Total
Age Group
<15 Years
15-19 Years
20-29 Years
30-65 Years
≥ 66 Years
5Unknown
Gender
Male
Female
Transgender , Male to Female
Transgender, Female to Male
Transgender, Not Specified
5Unknown
Gender of Sex Partners
Men who have sex with only men (MSM)
Women who have sex with only women (WSW)
Sex with both genders
Sex with opposite gender
Other
5Unknown
Race and Ethnicity
Hispanic or Latino
Not Hispanic or Latino	American Indian or Alaska Native
	Asian
	Black or African American
	Native Hawaiian or Pacific Islander
	White
	More than one race selected
5Unknown
Population Groups
Persons who inject drugs/Persons with substance use disorders
Women of reproductive age (15-49 years)
Persons experiencing homelessness
Sex workers
Insurance Status
6Private
7Public
8Uninsured
5Unknown
Data Quality
Are there missing/unavailable data for any performance measures in the table(s) above?
Please explain the issues with the missing data, including variable names, and your plans to enhance the completeness of your data (if applicable).
1	This is the number of UNIQUE people who received ANY sexual health services at your clinic in the specified reporting period. The number of people provided sexual health services should include people tested, screened, diagnosed, and/or treated or linked to care. The number of people who received preventive services should be a subset and cannot be greater than the number of people served. For unavailable or missing values, please enter the applicable numbers in the ‘unknown’ fields.
2	This is the number of people who received PrEP for HIV, in the specified reporting period. Count all persons who received one or more prescriptions for PrEP, including those who received it once and may have discontinued by the end of the reporting period. The number of people who received preventive services should be a subset and cannot be greater than the number of people served. For unavailable or missing values, please enter the applicable numbers in the ‘unknown’ fields.
3	This is the number of people who received nPEP for HIV, in the specified reporting period. Count all persons who received one or more prescriptions for nPEP, including those who received it once and may have discontinued by the end of the reporting period. The number of people who received preventive services should be a subset and cannot be greater than the number of people served. For unavailable or missing values, please enter the applicable numbers in the ‘unknown’ fields.
4	This is the number of people who received DoxyPEP for bacterial STIs, in the specified reporting period. Count all persons who received one or more prescriptions for DoxyPEP, including those who received it once and may have discontinued by the end of the reporting period. For unavailable or missing values, please enter the applicable numbers in the ‘unknown’ fields.
5	Unknown values for which the stratified data is missing or unavailable, e.g., numbers of people for whom their age groups are identified.
6	Private insurance includes plans provided through an employer or union, purchased by an individual, TRICARE, or other military coverage.
7	Public insurance includes plans funded by government at the federal, state, or local level. E.g., Medicaid, Medicare, Indian Health Service.
8	Uninsured includes persons not covered under any health insurance.

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Sheet 5: B-STI Diagnosis

STI Testing and Diagnosis
Aggregate Data Tables for PM-12, 13, 14
Black-out cells: Are not required for those measures and do not represent a reporting burden
Table B4. Persons Tested and Diagnosed with STIs and HIV
		Syphilis		Chlamydia		Gonorrhea		Mpox		HIV
		Number of Persons Tested1	Number of New Diagnosis2	Number of Persons Tested1	Number of New Diagnosis2	Number of Persons Tested1	Number of New Diagnosis2	Number of Persons Tested1	Number of New Diagnosis2	Number of Persons Tested1	Number of New Persons Testing Positive3
Total
Symptom Status
4Symptomatic (Tested)
5Asymptomatic (Screened)
6Unknown
Disease Stage
Primary
Secondary
Early Latent (EL)
Late Latent (LLS)
Neurosyphilis
6Unknown
Anatomic Site
Pharyngeal
Rectal
Urogenital
6Unknown
Age Group
<15 Years
15-19 Years
20-29 Years
30-65 Years
≥ 66 Years
6Unknown
Gender
Male
Female
Transgender, Male to Female
Transgender, Female to Male
Transgender, Not Specified
6Unknown
Gender of Sex Partners
Men who have sex with only men (MSM)
Women who have sex with only women (WSW)
Sex with both genders
Sex with opposite gender
Other
6Unknown
Race and Ethnicity
Hispanic or Latino
Not Hispanic or Latino	American Indian or Alaska Native
	Asian
	Black or African American
	Native Hawaiian or Pacific Islander
	White
	More than one race selected
6Unknown
Population Groups
Persons who inject drugs/Persons with substance use disorders
Women of reproductive age (15-49 years)
Persons experiencing homelessness
Sex workers
Data Quality
Are there missing/unavailable data for any performance measures in the table(s) above?
Please explain the issues with the missing data, including variable names, and your plans to enhance the completeness of your data (if applicable).
1	This is the number of people who were tested for: Syphilis, Gonorrhea, Chlamydia, Mpox, and HIV in the specified reporting period. For HIV, please include persons previously known or reported to be HIV positive, e.g., persons tested for confirmation prior to initiating treatment, in each reporting period. The number of people receiving preventive services should be a subset of, and cannot be greater than, the number of persons served. For unavailable or missing values, please enter the applicable numbers in the ‘unknown’ fields.
2	This is the number of new STI cases identified: Syphilis, Gonorrhea, Chlamydia, and Mpox, in the specified reporting period. This may include cases diagnosed in any previous reporting period and reinfected, then diagnosed in this reporting period. Please count only persons who had a positive test AND confirmed clinical diagnosis. New STI cases are the numbers of people who, at minimum, test positive after being tested in the specified reporting period, and should not be greater than the number of people tested. For unavailable or missing values, please enter the applicable numbers in the ‘unknown’ fields.
3	This is the number of persons that are newly diagnosed and were not tested and diagnosed in a previous reporting period. New HIV cases are the numbers of people who, at minimum, test positive after being tested in the specified reporting period, and should not be greater than the number of people tested. For unavailable or missing values, please enter the applicable numbers in the ‘unknown’ fields.
	Symptom Status: Refers to the number of persons screened, tested, and/or diagnosed due to the presence or absence of symptoms at the time of patient visit. (For example, a patient presenting with no throat or rectal symptoms but with urethral discharge, testing negative after urethral testing and positive for pharyngeal gonorrhea, after a 3-site gonorrhea/chlamydia screening, should be counted as symptomatic with reference to the gonorrhea test.)
4	Symptomatic (Tested): Number of persons presenting with symptoms and tested for listed STIs and/or HIV, at time of visit.
5	Asymptomatic (Screened): Number of persons with no symptoms and thus screened for possible Syphilis, Gonorrhea, Chlamydia, Mpox, and/or HIV, at time of visit.
6	Unknown values for which the stratified data is missing or unavailable, e.g., numbers of people for whom their age groups are identified.

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Sheet 6: B-Partner Svs_STI-HIV Treatment

	STI/HIV Treatment and Partner Services
	Aggregate Data Tables for PM-15, 16 & 17
	Black-out cells: Are not required for those measures and do not represent a reporting burden Gray cells: Auto-calculated and do not represent a reporting burden
	Table B5. Persons Treated for STI/HIV; Persons offered Partner Services Please enter the values for the number of new STI and HIV cases treated and/or initated on ART. (PM-15,16) Please enter the values for the number of new Syphilis and Mpox cases interviewed and offered partner services. (PM-17)
		Syphilis	Gonorrhea	Chlamydia	Mpox	HIV
	Number of new cases treated	N	N	N	N
	Number of new persons testing positive for HIV initiated on ART					N
	1Number of new cases referred to or offered partner services	N	N	N	N	N
	% of New Cases Treated/Initated on ART	%	%	%	%	%
	% of New cases referred to or offered partner services	%	%	%	%	%
	Data Quality
	Are there missing/unavailable data for any performance measures in the table(s) above?
	Please explain the issues with the missing data, including variable names, and your plans to enhance the completeness of your data (if applicable).
1	Partner Services are a broad array of services that should be offered to persons with STIs or HIV and their sexual or substance-use equipment (i.e., needles, syringes, etc.)-sharing partners. Please enter the values of the total number of STI cases and persons newly diagnosed with HIV who were referred to or offered partner services in the specified reporting period. This number can include persons referred to health departments (or other health partners) for partner services. For any disease areas for which your site/jurisdiction does not offer partner services, please leave blank and note this in the data quality field.

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Sheet 7: C-Expanded Access

Expanded Access to STI Prevention Care in Syndemic Approach
Data tables for PM-19, 20 & 21
Optional strategy, only completed by select clinics
Table C1: Expanded Access to STI Prevention Care in a Syndemic Approach (PM-19 - 21)
Performance Measure	Data Fields
Please describe the activities conducted in this reporting period to improve/increase access to quality sexual health services of local interest. Description should include methods, progress, and outcomes.
Please describe the demonstration or pilot projects conducted, in this reporting period, that addressed emerging and unaddressed STI/HIV/Viral hepatitis issues. Description should include methods, progress, and outcomes.
Please provide a summary of progress made to deliver alternative models of quality and comprehensive sexual health services. Description should include an overview of the project and progress achieved.