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HIV TESTING AND PREVENTION SERVICES TEMPLATE

05/28/2026 | Page 1 of 4

SECTION A. AGENCY, PROGRAM, AND CLIENT INFORMATION
(Complete for all clients, all settings)

Jurisdiction: (2-digit numeric code)
Form ID:
Session Date: MM/DD/YYYY
Program Announcement:
o PS24-0047 Core
o PS24-0047 EHE
o PS21-2102
o PS22-2203 Category A
o PS22-2203 Category B
o Other CDC-funded
o Other non-CDC-funded
If “Other CDC-funded” or “Other non-CDC funded”, please
specify: ____________________________________________________________

Agency Name:
Agency ID:

Client Ethnicity:
 Hispanic or Latino
 Not Hispanic or Latino

 Declined to answer
 Don’t know

Client Race: (select all that apply)
 American Indian or Alaska Native
 Asian
 Black or African American
 Native Hawaiian or Pacific Islander
Client Sex:

 White
 Not specified
 Declined to answer
 Don’t’ know

 Male  Female

Client Sexual Orientation:
 Straight or heterosexual
 Lesbian
 Gay
 Bisexual
 Another or a different sexual orientation
 Declined to answer
 Don’t know
In the past 5 years, has the client had:

CBO Agency ID:

a. Sex with a male
b. Sex with a female

Site Name:

c. Injected nonprescription drugs

Site ID:
Site Type: (see codes below)
Site Zip Code: (5-digit only)

Site County: (3-digit FIPS code)
Site State: (USPS abbreviation)

o No
o No
o No

o Yes
o Yes
o Yes

o Declined
o Declined
o Declined

o Don’t know
o Don’t know
o Don’t know

Has the client had an HIV test previously?
o No – never tested
o Yes – time of test unknown
o Yes – tested >12 months ago
o Yes – tested within ≤ 12 months
o Don’t know

Client State: (USPS abbreviation)

Entry Point to a CDC-Funded HIV Prevention Program:
o HIV testing and follow-up services
➔ ➔ Go to Section B ➔ ➔
o Services for persons already known to be positive for HIV
➔ ➔ Skip to Section C ➔ ➔
o Services for persons already known to be negative for HIV
➔ ➔ Skip to Section D ➔ ➔
o Services for persons with unknown HIV status who did not
receive HIV testing ➔ ➔ Skip to Section D ➔ ➔

Site Types: Clinical Setting

Site Types: Non-Clinical Setting

Local Client ID: (required for HDs; Optional for CBOs)
Client Year of Birth: (1800 if unknown)
Client Zip Code: (5-digit only)
Client County: (3-digit FIPS code)

F01.01

Clinical - Inpatient hospital

F02.12
F02.19
F02.51
F03
F08
F09
F10
F12
F13
F16
F18
F19
F20

Clinical - TB clinic
Clinical - Substance abuse treatment facility
Clinical - Community health center (CHC)
Clinical - Emergency department
Clinical - Primary care clinic (other than CHC)
Clinical - Pharmacy or other retail-based clinic
Clinical - STD clinic
Clinical - Correctional facility clinic
Clinical - Other clinical site
Clinical - Health department clinic (single/multiple service)
Clinical - Syringe services program (clinic based)
Clinical - PrEP services clinic
Clinical - Urgent care clinic

F04.05
Non-clinical - HIV testing site
F06.02
Non-clinical - School/ educational facility
F06.03
Non-clinical - Church/ mosque/ synagogue/temple
F06.04
Non-clinical - Shelter/ transitional housing
F06.05
Non-clinical - Commercial facility
F06.07
Non-clinical - Bar/club/adult entertainment
F06.08
Non-clinical - Public area
F06.12
Non-clinical - Individual residence
F07
Non-clinical - Correctional facility
F14
Non-clinical - Health department field visit or other site
F22
Non-clinical - Syringe services program - fixed site
F21
Non-clinical - PrEP services site
F88
Non-clinical - Other community site
Site Types: Mobile Units
F41
Mobile unit - Non-syringe services program
F42
Mobile unit - Syringe services program

HIV TESTING AND PREVENTION SERVICES TEMPLATE

05/28/2026 | Page 2 of 4

SECTION B. HIV TESTING AND FINAL TEST INFORMATION
(Complete for clients receiving HIV testing, all settings)

HIV testing strategy used to provide current test:
o Routine opt-out screening in health care sites
o Non-routine opt-out testing in health care sites
o Non-routine opt-out testing in non-health care sites
o Partner notification and testing
o Outreach testing
o Self-testing – Rapid testing
o Self-testing – Mail-in testing
o Other testing strategy
o Don’t know
What was the final test result for the current test?
 Preliminary positive
 Negative
 Invalid

 Positive
 Discordant
 Result unavailable

Surveillance or
Other Data Checks for
Persons with
Diagnosed HIV

➔ ➔ If “Negative,” or “Discordant,” “Invalid,” or “Result unavailable,” skip to question “Was the current HIV test result provided to client”? ➔ ➔
If client is diagnosed with HIV, was it a new or previous diagnosis?
o New diagnosis, verified
o Previous diagnosis

 New diagnosis, not verified
 Unable to determine

If “previous diagnosis” or “unable to determine,” has the client seen a medical care provider in the past six months for HIV treatment?
 No
 Yes
 Declined to answer
 Don’t know
eHARS State Number:
eHARS City/County Number:

Was the current HIV test result provided to client?

 No

Is the current HIV test a follow-up to confirm a self-test result?

 Yes

 Yes, client obtained the result from another agency
 No

 Yes

 Don’t know

SECTION C. SERVICES FOR PERSONS DIAGNOSED WITH HIV
(Complete for all clients with HIV, all settings)

Did the client need any of the following services: linkage to/reengagement in HIV care, prescription for antiretroviral treatment, or HIV partner services?
 No
 Yes
 Don’t know
➔ ➔ If “No,” skip to Section D ➔ ➔
Linkage to or Re-engagement in HIV Medical Care
Was the client provided navigation or other linkage services to facilitate linkage to or re-engagement in HIV medical care?
 No
 Yes
 Don’t know
Did the client attend an HIV medical care appointment after session date?
 No
 Yes – confirmed
 Yes – client/patient self-report
 Don’t know
If “Yes,” date attended: MM/DD/YYYY
Antiretroviral Treatment (ART)

HIV Partner Services (PS)

Did the client receive a prescription for HIV antiretroviral treatment (ART)
after session date?
 No
 Yes – confirmed
 Yes – client/patient self-report
 Don’t know

Was the client's contact information provided to the health department for
HIV Partner Services?
 No
 Yes
 Don’t know

If “Yes,” how long after session date did the client receive an ART
prescription?
o ≤ 7 days
 8-30 days
o 31-60 days
 61-90 days
o ≥91 days
 Don’t know

Was the client interviewed for HIV Partner Services?
 No
 Yes
If “Yes,” date of interview: MM/DD/YYYY

 Don’t know

HIV TESTING AND PREVENTION SERVICES TEMPLATE

05/28/2026 | Page 3 of 4

SECTION D. INTEGRATED TESTING AND DIAGNOSIS OF CO-INFECTIONS
(Complete for clients tested for HIV during this session, all settings)

Was the client tested for co-infections?
 No  Yes
 Don’t know

➔ ➔ IF “No” or “Don’t know, ” Skip to Section E ➔ ➔

If ‘Yes,’ indicate which infection the client was tested for, the results of the tests (optional), and referral or treatment for those with a diagnosis (optional)
Tested?

If tested, what was the test result?

(Skip to next item if
(Skip to next item if “Negative” or ”Don’t know” test results)
“No” to testing)

If positive, was the client referred to/provided treatment?

Syphilis

 No

 Yes

 New Positive

 Negative

 Don’t know

 Referred

 Provided treatment

 No action

Gonorrhea

 No

 Yes

 Positive

 Negative

 Don’t know

 Referred

 Provided treatment

 No action

Chlamydia

 No

 Yes

 Positive

 Negative

 Don’t know

 Referred

 Provided treatment

 No action

Hepatitis C

 No

 Yes

 Positive

 Negative

 Don’t know

 Referred

 Provided treatment

 No action

Hepatitis B

 No

 Yes

 Positive

 Negative

 Don’t know

 Referred

 Provided treatment

 No action

TB

 No

 Yes

 Positive

 Negative

 Don’t know

 Referred

 Provided treatment

 No action

Mpox

 No

 Yes

 Positive

 Negative

 Don’t know

 Referred

 Provided treatment

 No action

Other*

 No

 Yes

 Positive

 Negative

 Don’t know

 Referred

 Provided treatment

 No action

* If “Other,” specify what the other infection or condition the client was tested for:__________________________________________________________________

SECTION E. PrEP/PEP SERVICES
PrEP SERVICES
PrEP AWARENESS AND USE (Complete for all clients, all settings)
Has the client ever heard of PrEP before today?
Was the client provided education/information on PrEP?
Has the client ever used PrEP?

o No - Never used PrEP
(Skip to PrEP Screening)

Is the client currently taking PrEP?

o No
o No
o Yes - Used PrEP >12 months ago

o Yes
o Yes
o Yes – Used PrEP within ≤12

o No

o Yes

(Skip to PrEP Screening)

months

(Skip to PEP Services)

PrEP SCREENING AND FOLLOW-UP SERVICES (Complete for HIV-negative clients, all settings)
Client can benefit from or interested in PrEP?

o No (Skip to PEP Services)

o Yes – Self-interest

o Yes – Provider recommendation

Was the client referred to a PrEP provider?

o No

o Yes – Referral accepted

o Yes – Referral offer declined

Was the client provided navigation or linkage
services to a PrEP provider?

o No

o Yes

o Don’t know

Was the client linked to a PrEP provider?

o No

o Yes

Was the client prescribed PrEP?

o No

o Yes

o Not needed

o Not eligible

PEP SERVICES
PEP AWARENESS (Complete for all clients, all settings)
Has the client ever heard of PEP before today?

o No

o Yes

Was the client provided education/information on PEP?

o No

o Yes

PEP SCREENING AND FOLLOW-UP SERVICES (Complete for HIV-negative clients, all settings)
Client can benefit from PEP?
Was the client prescribed PEP?
(OPTIONAL)

o No
o No

(Skip to Section F)

o Yes
o Yes

o Not eligible

HIV TESTING AND PREVENTION SERVICES TEMPLATE

05/28/2026 | Page 4 of 4

SECTION F. ESSENTIAL SUPPORT SERVICES
(Complete for all clients, all settings)

Was the client screened for, referred to, or provided one or more of the essential support services listed below?
o No – Services were not available at this agency
o No – Services were available, but client was not offered any service
➔ ➔ If “No,” skip to END ➔ ➔
(e.g., because services were limited to PWH only)
o No – Services were available, but client refused all services
o Yes – Client received one or more services (screening, referral, or assistance)
If ‘Yes’ to the above question, indicate which services the client was screened for, referred to a provider, or provided the needed services.
Essential Support
Service Type

Screening and Identification of Needs

If “Screened - Need Identified,”

(* Skip to next item if “Not Screened”, or “Screened- No need
identified”)

Referral or Provision of Needed Services

o Not
Mental Health Services

screened*

o Not
Substance Use Services

screened*

o Not
Housing Services
Health Benefits or
Insurance Navigation

screened*

o Not
screened*

o Not
Social Services
Harm Reduction/
Syringe Services

screened*

o Not
screened*

o Screened –
No need identified*

o Screened –
No need identified*

o Screened –
No need identified*

o Screened –
No need identified*

o Screened –
No need identified*

o Screened –
No need identified*

o Screened –
Need identified

o Screened –
Need identified

o Screened –
Need identified

o Screened –
Need identified

o Screened –
Need identified

o Screened –
Need identified

o Not
offered

o Not
offered

o Not
offered

o Not
offered

o Not
offered

o Not
offered

o Offered but o Referred to o Provided
declined

a provider

needed service

o Offered but o Referred to o Provided
declined

a provider

needed service

o Offered but o Referred to o Provided
declined

provider

needed service

o Offered but o Referred to o Provided
declined

a provider

needed service

o Offered but o Referred to o Provided
declined

a provider

needed service

o Offered but o Referred to o Provided
declined

a provider

END OF CLIENT-LEVEL DATA REQUIREMENTS
(Jurisdiction-Level Aggregate Data Requirements for HDs on Next Page)

needed service

JURISDICTION-LEVEL AGGREGATE DATA REQUIREMENTS
05/28/2026 | Page 1 of 1
#

AGGREGATE MEASURE OR QUALITATIVE QUESTION

STRATIFICATION

Strategy 1: Diagnose
HIV Testing at PS-24-0047 Funded Facility to Conduct Routine Screening
1

2

3
4
5
6
7

# of people seen during the prior 12-month service period at a health care facility conducting

Age, race and ethnicity, sex, sexual

routine opt-out HIV screening who were eligible for a routine opt-out HIV test

orientation, pop group, facility name

# of people eligible for a routine opt-out HIV test seen during the 12-month service period at a

Age, race and ethnicity, sex, sexual

health care facility conducting routine opt-out HIV screening who were screened for HIV

orientation, pop group, facility name

Partner Services in PS-24-0047 Supported Jurisdiction (Not NOFO Specific)

(Measures apply to Strategies 1- 3)

# of index patients with newly or previously diagnosed HIV contacted by PS program who
were interviewed for PS within 30 days and anytime frame after diagnosis
# of notifiable partners named who were notified of their exposure to HIV
# of tested partners who were newly or previously diagnosed with HIV infection
# of partners with newly diagnosed HIV or partners with previously diagnosed HIV not in care
who were linked to care within 30 days and anytime frame after contact by PS program
# of partners without HIV (HIV-negative) and not on PrEP who were referred to a PrEP
provider
PS-24-0047 Funded HIV Self-Testing

8

# of PS-24-0047 funded HIV self-test kits distributed

9

# of people who received at least one HIV self-test kit

10

# of people who received at least one HIV self-test kit who were diagnosed with HIV
# of people with newly diagnosed HIV or people with previously diagnosed HIV not in care

11

identified through self-testing who were linked to care within 30 days and anytime frame after

diagnosis
Strategy 2: Treat
PS-24-0047 Supported Linkage, Reengagement, Treatment, and Support Services for PWH*
Strategy 3: Prevent
PS-24-0047 Funded Condom Distribution
12 # of PS-24-0047-funded condoms distributed
Harm Reduction or Syringe Services in PS-24-0047 Supported Jurisdictions*
# of syringe services programs (SSPs) operating in the jurisdiction – Supported by PS-24-

No stratification
No stratification
No stratification
No stratification
No stratification

Rapid tests (required) vs. mail-in
home specimen collection (optional)
Age, race and ethnicity, sex, sexual
orientation, pop group,
Age, race and ethnicity, sex, sexual
orientation, pop group,
Age, race and ethnicity, sex, sexual
orientation, pop group,

N/A

Fixed vs. Mobile
13 0047
Overall PS-24-0047 Program: Success Stories by Strategy/Activity and Focused Local Evaluations
Describe your success stories on selected program strategies/activities, including story title/headline, a summary, issues or
14
15

challenges encountered, intervention or solution implemented, result or impact achieved, and sustainability plan.
If your jurisdiction conducts focused local evaluation, please provide a brief description of the program or strategy evaluated, the
evaluation timeline, target population, evaluation methods, and key findings (including aggregate data tables to support your
findings).

* TEB plans to conduct small scale evaluation activities on SSPs and other innovative activities and strategies with selected jurisdictions
that have the capacity to monitor them as part of focused local evaluation efforts.