Cluster Close-out Form

Form Approved

OMB No. 0920-0573

Expiration Date: 02/28/2026

Attachment 3g

Cluster Close-Out Form

Public reporting burden of this collection of information is estimated to average 1 hour 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 (0920-0573)

ANNUAL/CLOSEOUT FORM

Cluster Variables

1. Date form completed: ______________________ (MM-DD-YYYY)

2. Local cluster ID: [auto-populated from initial form]

3. CDC cluster ID: [auto-populated from initial form]

Status of Cluster Response

4. Are investigation or response activities for this cluster currently ongoing?

   1. Yes (this is an Annual Form)

   2. No (this is a Closeout Form)

4a. [If answered No for 4] Date cluster investigation and response activities closed: ____ (MM-DD-YYYY)

4b. [If answered No for 4] Reason(s) for closeout: ______________________

Case Definition and Characteristics

5. Since the last time you submitted a cluster report form for this cluster, has the cluster case definition changed?

   1. Yes

   2. No

5a. [If answered yes for 5] Describe changes to the cluster case definition: ______________

5. Since the last time you submitted a cluster report form for this cluster, have there been any notable changes to the characteristics of the cluster?

   1. Yes

   2. No

6a. [If answered yes for 6] Describe notable changes to the characteristics of the cluster: ______________

5. Number of people with HIV in the cluster residing in your jurisdiction at the time of this report: ____

5. Number of people with HIV in the cluster residing in your jurisdiction who had completed a partner services interview at the time of this report: ____

5. Number of named partners of cluster members not known to have HIV residing in your jurisdiction at the time of this report: ____

5. Number of unnamed, marginal, and anonymous partners of cluster members at the time of this report: ____

Overlapping Clusters

11. Since the last time you submitted a cluster report form for this cluster, has this cluster been newly identified as overlapping with a cluster identified by a different method?

1. Yes

2. No

11a. [If answered yes for 11] Select the method of identification, date of detection and Cluster ID of the overlapping cluster(s).

Method of identification: ______________________

Date of detection: ______________________

Cluster ID: ______________________

Instructions: For overlapping molecular or time-space clusters identified by CDC, the date of detection should be populated with the date your jurisdiction was notified of the existence of the cluster by CDC.

11b. [OPTIONAL] [If answered yes for 11] Include any relevant additional information on the overlapping clusters: ___________________

Gaps or Challenges

12. What gaps or challenges have you encountered in responding to this cluster? Check all that apply.

1. Limited ability to conduct partner services

2. Limited understanding of factors facilitating transmission

3. Limited knowledge about HIV testing, care, prevention, or other related topics among people in the network or providers

4. Limited access to or acceptability of HIV testing

5. Limited access to or acceptability of HIV care

6. Limited access to or acceptability of HIV prevention (e.g., PrEP, SSPs)

7. Limited access to or acceptability of testing, care, or prevention due to structural issues or for syndemic conditions

8. Other

12a. [OPTIONAL] Provide additional information on any of the selected challenges: __________

Investigation or Response Activities

12. What investigation or response activities have you initiated in response to the cluster?

Instructions: Check off all the activities that have been part of your cluster response. Your response should reflect a cumulative list of all activities that have been initiated, tailored, or enhanced in response to the cluster except for reporting on activities 1-3 related to individual cluster member/partner follow-up. You may check off activities 1-3 even if they were initiated before the identification of the cluster. Note that if you are unsure of where an activity fits within a domain you can place it in the “other” category of the domain.

Domain 1: Individual cluster member/partner follow-up (“Partners” refers to the sexual and drug equipment-sharing partners of cluster members.)

• Tested cluster members’ partners and social contacts for HIV [Activity 1]

• Linked or re-engaged cluster members with HIV in care [Activity 2]

• Referred cluster members' partners to PrEP or PEP services [Activity 3]

• Other [Activity 4]

  • Specify ______________________________

Domain 2: Investigation/gathering additional information

• Used qualitative methods (e.g., in-depth qualitative interviews, focus groups, or surveys) with members of the cluster, network, or affected communities to understand barriers and improve response activities [Activity 5]

• Used qualitative methods (e.g., in-depth qualitative interviews, focus groups, or surveys) with clinical providers, leaders or staff of community organizations, or other community members to understand barriers and improve response activities [Activity 6]

• Conducted detailed medical chart reviews (i.e., beyond what is usually done for surveillance purposes) for cluster members to understand patterns of, missed opportunities for, and other aspects of prevention and care [Activity 7]

• Other [Activity 8]

  • Specify ______________________________

Domain 3: Communication and training

• Engaged with network or affected communities (e.g., placed advertisements, including social media, or conducted other specific outreach to network/affected community) [Activity 9]

• Trained clinical providers on the needs of the cluster or network such as HIV testing, prevention, care, substance use disorders, harm reduction strategies, structural factors affecting health, culturally competent care, linguistic and cultural humility, and other relevant topics [Activity 10]

• Communicated with clinical providers during the cluster response (e.g., issued health alert or Dear Colleague letter or hosted a meeting with providers) [Activity 11]

• Engaged with broader community organizations or general public during cluster response (e.g., held community information sessions, issued a press release, worked with the media) [Activity 12]

• Other [Activity 13]

  • Specify________________________________

Domain 4: HIV testing

• Expanded or enhanced HIV testing that focuses on the network or affected communities [Activity 14]

• Expanded or enhanced HIV testing beyond the network or affected communities by establishing new testing services or increasing the availability or accessibility of existing testing services, including low-barrier testing [Activity 15]

• Provided HIV self-testing for network members or affected communities [Activity 16]

• Expanded or enhanced access to HIV self-testing beyond the network or affected communities [Activity 17]

• Other [Activity 18]

  • Specify________________________________

Domain 5: HIV care

• Expanded or enhanced activities to improve engagement in care or viral suppression for cluster members [Activity 19]

• Expanded or enhanced HIV care access beyond the cluster by establishing new clinical services or increasing the availability or accessibility of existing clinical services, including low-barrier care [Activity 20]

• Expanded or enhanced HIV care coordination or navigation services [Activity 21]

• Other [Activity 22]

  • Specify________________________________

Domain 6: HIV prevention

• Expanded or enhanced PrEP/PEP access for network members or affected communities [Activity 23]

• Expanded or enhanced PrEP/PEP access beyond the network by establishing new clinical services or increasing the availability or accessibility of existing clinical services [Activity 24]

• Provided or expanded access to harm reduction programs and syringe services programs (SSPs) to eligible network members [Activity 25]

• Provided or expanded access beyond the network or affected communities to harm reduction programs and SSPs by establishing new programs or increasing the availability or accessibility of existing programs [Activity 26]

• Other [Activity 27]

  • Specify________________________________

Domain 7: Syndemic and structural interventions

• Referred cluster or network members to housing services [Activity 28]

• Referred cluster or network members to substance use treatment services [Activity 29]

• Referred cluster or network members to mental health services [Activity 30]

• Linked cluster or network members to testing, treatment, or prevention for gonorrhea, chlamydia, syphilis, hepatitis B, hepatitis C, tuberculosis, or mpox [Activity 31]

• Distributed naloxone kits for overdose prevention to the network or affected communities [Activity 32]

• Implemented activities that address structural factors that can impact access to prevention and care services [Activity 33]

• Other [Activity 34]

  • Specify________________________________

13a. Did you only check off activities in Domain 1?

1. Yes

2. No

13b. [If answered Yes for 13a] Describe why response activities were limited to individual cluster member/partner follow-up.

12. Reporting the outcomes of cluster response activities

[List of checked activities will be autopopulated]

Instructions: Pick at least three of the activities you checked off in question 16 for which you will report on outcomes. The three activities should come from at least two different domains unless you only implemented activities from a single domain.

For activities 1-3, provide the numerical value for the outcome(s) as per the table in the Cluster Report Form Instructions document.

For all the other activities (activity numbers 4-34):

• Describe the activity (what was done; who was the intended audience; who carried out the activity; how, where, and when was the activity implemented)

• Indicate the current status (pick one)

  • Planned

  • In Progress

  • Completed

• Provide outcomes

  • For activities 4, 5, 6, 7, 8, 9, 11, 12, 13, 18, 19, 21, 22, 23, 25, 27, 31, 33, 34, describe the outcome of the activity and how it was measured

  • For activities 10, 14, 15, 16, 17, 20, 24, 26, 28, 29, 30, or 32 refer to the table in the instructions for the required numerical outcomes and provide the result(s)

12. Describe any changes to policies or processes to support the prevention, diagnosis, and treatment of HIV in your jurisdiction implemented in response to this cluster, including any successes or innovations not reported in question 14.

12. [OPTIONAL] If the cluster or network includes persons outside of your jurisdiction, have you contacted other jurisdictions involved?

    1. Yes

    2. No

    3. No cluster or network members outside of the jurisdiction

16a [OPTIONAL] [If answered yes for 16] Describe any collaboration or communication with other jurisdictions involved: ______________________

Level of Concern

12. [If answered Yes for 4] What is your current level of concern for this cluster?

1. High

2. Medium

3. Low

Instructions: Consider a variety of factors that may modify your level of concern. See Cluster Review and Prioritization “Questions to consider when developing prioritization criteria” section in CDC’s HIV CDR Guidance for Health Departments for additional considerations.

17a. [If answered High for 17] Describe why you've assigned this level of concern using a brief, narrative summary of key findings: ________________________

Instructions: In the narrative summary, include any notable or concerning epidemiological or other characteristics, including any indications that the underlying network is substantially larger than what has been identified.

Technical Assistance Needs

12. [If answered Yes for 4] Do you have any technical assistance needs related to this cluster?

a. Yes

b. No

18a. [If answered Yes for 18] Describe your technical assistance needs. (Note: If you have urgent technical assistance needs, reach out directly to your assigned Detection and Response Branch epidemiologist.) _____________

Additional Comments

12. [OPTIONAL] Additional comments ______________

10