Form 1 Ending the HIV Epidemic (EHE) Triannual Report

OMB No. 0906-XXXX
Expires: XX/XX/202X

Proposed EHE Triannual Module Instrument

The table below should only include information for clients who received
at least 1 services in the previous 4 month reporting period

# of New Clients
who received
service(s) in the
reporting period1

# of Clients who
received service(s) in
the reporting period and
received at least one
service in the previous
year2

Total # of Clients who
received service(s) in
the reporting period

#

#

#

Initiative Services3

#

#

#

Outpatient Ambulatory Health Services4

#

#

#

Medical Case Management Services4

#

#

#

Non-medical Case Management Services4

#

#

#

Mental Health Services4

#

#

#

Substance Abuse Outpatient Care
Services4

#

#

#

Substance Abuse Services (Residential) 4

#

#

#

Housing Services4

#

#

#

#

#

#

RWHAP/ Initiative Services
Any RWHAP or Initiative Service

Health Outcomes
Prescribed ART in the reporting period
1Any

RWHAP client who has not received services from the service provider in the past.

2Any

RWHAP client who did received a service from the service provider in the previous calendar year.

3Initiative
4Refer

Services include those services that are funding through Initiative funding but do not meet the definition of a RWHAP service, as outlined in .

to PCN 16-02 for information on service category definitions.

Public Burden Statement: The purpose of this data collection system is to collect aggregate data on the number of new and existing clients, and clients
who have been out of care treated with EHE initiative funding. HAB will use these data to show the impact of the increased funding on reducing new
HIV infections, identifying new HIV infections, engaging clients in care and treatment. 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. The OMB control number for this information
collection is 0906-0051 and it is valid until XX/XX/202X. This information collection is mandatory (through increased Authority under the Public Health
Service Act, Section 311(c) (42 USC 243(c)) and title XXVI (42 U.S.C. §§ 300ff-11 et seq.). Public reporting burden for this collection of information is
estimated to average 1 hour per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing
the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions
for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 13N82, Rockville, Maryland, 20857 or [email protected].