0920-1282 SHIPS Biannual Performance Measures

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SHIPS Biannual Performance Measures

Document Drafted November 2024 Form Approved
OMB Control Number: 0920-1282
Expiration Date: 06/30/2026
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automatically saved and can be resumed via the same link.Form to be completed by SHIPS recipients biannually in
September and March. The estimated time to complete it is 60 minutes.

Clinic Volume in Reporting Period Volume tables should capture total numbers and not be
limited to unique patients.

Volume of Visits Conducted in the Reporting Period
Total number of clinic visits conducted
______
Are there any data limitations, including reasons
unable to report, in the table above?
Please explain the data issues and your clinic's plans
to enhance the completeness of your data.

Yes
No

__________________________________________

Volume of Tests Conducted in the Reporting Period
Total number of tests conducted for syphilis Total number of tests conducted for chlamydia Total number of tests
conducted for gonorrhea Total number of tests conducted for Mpox Total number of tests conducted for HIV STI Test
Volume (Total # of syphilis, chlamydia, gonorrhea, and Mpox tests)
______ ______ ______ ______ ______ [bipm_14]
Volume of Cases Diagnosed in the Reporting Period
Total number of cases diagnosed for syphilis Total number of cases diagnosed for chlamydia Total number of cases
diagnosed for gonorrhea Total number of cases diagnosed for Mpox
______ ______ ______ ______
Volume of Cases Treated in the Reporting Period
Total number of cases treated for syphilis Total number of cases treated for chlamydia Total number of cases
treated for gonorrhea Total number of cases treated for Mpox
______ ______ ______ ______
Volume of Vaccines Administered in the Reporting Period
Total number of mpox vaccines administered
______
STI test volume (syphilis, chlamydia, gonorrhea, and
Mpox)
Are there any data limitations, including reasons
unable to report, in the table above?
Please explain the data issues and your clinic's plans
to enhance the completeness of your data.

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__________________________________
Yes
No

__________________________________________

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CDC estimates the average public reporting burden for this collection of information as 57 hours annually, including
the time for reviewing instructions, searching existing data/information sources, gatgering and maintained the
data/information 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/ASTDR Information Collection Review Office, 1600
Clifton Rd NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-1282)

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Priority Populations Served in the Reporting Period How successful was your clinic at
reaching priority populations this reporting period? Please provide the number of persons
served during the reporting period. 
Note that race/ethnicity, population group, and sexual orientation table counts may not be
mutually exclusive. For example, one person may fall into multiple racial/ethnic categories and
therefore race/ethnicity numbers may not sum to 100%. OMB published Revisions to OMB's
Statistical Policy Directive No. 15 on 3/29/2024.  The new Standards require CDC to collect
race/ethnicity data in the manner below. Of note, an "other" race/ethnicity option is to be
removed, a Middle Eastern or North African category is to be added, and racial and ethnic
categories are considered "select all that apply". For more information, see the SHIPS data
entry guidance document.

Race/Ethnicity
Is your clinic able to collect and extract data for this demographic variable?   Count
______ Hispanic or Latino ______
______ White ______
______ Black/African American ______
______ Asian ______
______ American Indian/Alaskan Native ______
______ Native Hawaiian/Pacific Islander ______
______ Middle Eastern or North African ______
  Missing, unknown, or unable to disaggregate
______
Population Group
Is your clinic able to collect and extract data for this demographic variable?   Count
______ Persons who are unhoused/persons experiencing homelessness
______
______ Women of reproductive age
______
______ Pregnant women
______
______ Persons who inject drugs
______
Age Group
Is your clinic able to collect and extract data for this demographic variable?
  Count
______ Under 15 years ______
______ 15-19 years ______
______ 20-29 years ______
______ 30-64 years ______
______ 65 years and older ______
  Missing, Unknown, or Unable to Disaggregate Variable ______

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Sex
Is your clinic able to collect and extract data for this variable?   Count
______ Male ______
______ Female ______
______ Undetermined ______
  Missing ______

Sexual Orientation
Is your clinic able to collect and extract data for this variable?   Count
______ Gay
______
______ Lesbian
______
______ Straight, that is, not lesbian or gay
______
______ Bisexual
______
  Missing, Unknown, or Unable to Disaggregate Variable ______
Are there any data limitations, including reasons
unable to report, in the table above?
Please explain the data issues and your clinic's plans
to enhance the completeness of your data.

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Yes
No

__________________________________________

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Unique Persons Served in the Reporting Period How successful was your clinic at serving
priority populations this reporting period? Please provide the number of persons served
during the reporting period. 
Number of persons who are HIV positive includes new and previous diagnoses and
self-reports.

Number of Unique Persons Served in the Reporting Period

______

HIV status of unique persons served in the reporting period Number of persons who are HIV positive Number of
persons who are HIV negative Number of persons whose HIV status is unknown Total number of persons served in
the reporting period ______ ______ ______ [totalnumserved]
humber served by HIV status

Are there any data limitations, including reasons
unable to report, in the table above?
Please explain the data issues and your clinic's plans
to enhance the completeness of your data.

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__________________________________
Yes
No

__________________________________________

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Prevention Interventions in the Reporting Period
Please provide your clinic's PrEP eligibility
definition:

__________________________________________

Prevention Interventions
Is your clinic able to collect and extract data for this variable?   Count
______ Number of unique persons who were prescribed HIV nPEP  ______
______ Number of unique persons prescribed or given doxyPEP ______
______ Number of unique persons PrEP eligible  ______
______ Number of unique persons already on PrEP as prescribed at/by clinic [refill/maintenance]  ______
______ Number of unique persons referred to a PrEP provider [internally or in-house]  ______
______ Number of unique persons referred to a PrEP provider [externally]  ______
______ Number of unique persons prescribed PrEP at/by clinic [Initial Prescription]  ______

Are there any data limitations, including reasons
unable to report, in the Prevention Interventions
tables above?
Please explain the data issues and your clinic's plans
to enhance the completeness of your data.

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Yes
No

__________________________________________

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Diagnoses and Treatment in the Reporting Period

 Diagnoses and Treatment in the Reporting Period
Is your clinic able to collect and extract data for this variable?   Count
______ Number of unique persons tested for HIV
______
______ Number of unique persons newly diagnosed with HIV
______
______ Number of unique persons newly diagnosed with HIV & linked to care within 7 days of diagnosis [internally or
in-house]
______
______ Number of unique persons newly diagnosed with HIV & linked to care within 7 days of diagnosis [externally]
______
______ Number of unique persons newly diagnosed with HIV though unlinked to care within 7 days of diagnosis/Lost
to follow-up
______

Are there any data limitations, including reasons
unable to report, in the table above?
Please explain the data issues and your clinic's plans
to enhance the completeness of your data.

Yes
No

__________________________________________

When you are finished, please click the **"Submit"** button to ensure your responses are recorded. The next screen
will allow you to download your answers. You should also receive a confirmation email with your submission as a PDF.

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