Att 3B_HIV Testing and Prevention Services Template- CBO

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HIV TESTING AND PREVENTION SERVICES TEMPLATE – WORD FORMAT
SECTION A. AGENCY, PROGRAM, AND CLIENT INFORMATION
(Complete this section for all clients in all settings.)
A1. Jurisdiction (A02): (2 digit numeric code)
A2. Form ID (H04a): ____________________________________
A3. Session Date (H06): MM/DD/YYYY
A4a. Program Announcement (X137):
○
○
○
○
○
○
○

PS24-0047 Core
PS24-0047 EHE
PS21-2102
PS22-2203 Category A
PS22-2203 Category B
Other CDC-funded
Other non-CDC-funded

A4b. If “Other CDC-funded” or “Other non-CDC funded”, please specify (X137-1): ___________________
A5. Agency Name (A01):
A6. Agency ID (A01a):

A7. CBO Agency ID (A28):

A8. Site Name (S03):
A9. Site ID (S01):

A10.Site Type (S20): (Select one from codes below)

A11. Site Zip Code (S10): (5-digit only)

A12. Site County (S08): (3-digit FIPS code)

A13. Site State (S09): (USPS abbreviation)

A14. Local Client ID (G103):

A15. Client Year of Birth (G112): (1800 if unknown)

A16. Client Zip Code (G134): (5-digit only)

A17. Client County (G132): (3-digit FIPS code)

A18. Client State (G120): (USPS abbreviation)

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A19. Client Ethnicity (G114):
○ Hispanic or Latino
○ Not Hispanic or Latino
○ Declined to answer
○ Don’t know
A20. Client Race (G116): (select all that apply)
 American Indian or Alaska Native
 Asian
 Black or African American
 Native Hawaiian or Pacific Islander
 White
 Not specified
 Declined to answer
 Don’t’ know
A21. Client Sex (G140):
○ Male

○ Female
A22. Client Sexual Orientation (G141):)
○ Straight or heterosexual

○ Lesbian
○ Gay
○ Bisexual
○ Another or a different sexual orientation
○ Declined to answer
○ Don’t know
A23. In the past 5 years, has the client had sex with a male? (G400)

○ No

○ Yes

○ Declined

○ Don’t know

A24. In the past 5 years, has the client had sex with a female? (G401)

○ No

○ Yes

○ Declined

○ Don’t know

A25. In the past 5 years, has the client injected non-prescription drugs? (G402)

○ No

○ Yes

○ Declined

○ Don’t know

A26. Has the client had an HIV test previously? (G404)
○ No – never tested
○ Yes – date of test unknown
○ Yes – tested >12 months ago
○ Yes – tested within ≤ 12 months
○ Don’t know
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A27. What is the client’s entry point into a CDC-funded HIV prevention program? (H24)
○
○
○
○

HIV testing and follow-up services ➔ ➔ Go to Section B ➔ ➔
Services for persons already known to be positive for HIV ➔ ➔ Skip to Section C ➔ ➔
Services for persons already known to be negative for HIV ➔ ➔ Skip to Section D ➔ ➔
Services for persons with unknown HIV status who did not receive HIV testing ➔ ➔ Skip to
Section D ➔ ➔

Site Types: Clinical Setting
F01.01
Clinical - Inpatient hospital
F02.12
Clinical - TB clinic
F02.19
Clinical - Substance abuse treatment facility
F02.51
Clinical - Community health center (CHC)
F03
Clinical - Emergency department
F08
Clinical - Primary care clinic (other than CHC)
F09
Clinical - Pharmacy or other retail-based clinic
F10
Clinical - STD clinic
F12
Clinical - Correctional facility clinic
F13
Clinical - Other clinical site
F16
Clinical - Health department clinic (single/multiple service)
F18
Clinical - Syringe services program (clinic based)
F19
Clinical - PrEP services clinic
F20
Clinical - Urgent care clinic
Site Types: Non-Clinical Setting
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

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SECTION B. HIV TESTING AND FINAL TEST INFORMATION
(Complete for all clients receiving HIV testing, all settings)
B1. HIV testing strategy used to provide current test (X100):
○
○
○
○
○
○
○
○
○

Routine opt-out screening in health care sites
Non-routine opt-out testing in health care sites
Non-routine opt-out testing in non-health care sites
Partner notification and testing
Outreach testing
Self-testing – Rapid testing
Self-testing – Mail-in testing
Other testing strategy
Don’t know

B2. What was the final test result for the current test? (X140)

○
○
○

○
○
○

Preliminary positive
Negative
Invalid

Positive
Discordant
Result unavailable

➔ ➔ If “Negative,” “Discordant,” “Invalid,” or “Result unavailable,” skip to B7 ➔ ➔

Surveillance
or Other Data
Checks for
Persons with
Diagnosed HIV

B3. If client is diagnosed with HIV, was it a new or previous diagnosis? (X138)
○ New diagnosis, verified
○ New diagnosis, not verified
○ Previous diagnosis
○ Unable to determine
B4. If “previous diagnosis” or “unable to determine,” has the client seen a medical
care provider in the past six months for HIV treatment? (X740)
○ No

○ Yes

○ Declined to answer

○ Don’t know

B5. eHARS State Number (H04c):
B6. eHARS City/County Number (H04d):

B7. Was the HIV test result provided to client? (X111)
○

No

○

Yes

○ Yes, client obtained the result from another agency

B8. Is the current test a follow-up to confirm a self-test result? (X123)
○ No

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○ Yes

○ Don’t know

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SECTION C. SERVICES FOR PERSONS DIAGNOSED WITH HIV
(Complete for clients with HIV, all settings)
C1. Did the client need any of the following services: linkage to/reengagement in HIV care,
prescription for antiretroviral treatment, or HIV partner services? (X142)
○ No

○ Yes

○ Don’t know

➔ ➔ If “No,” skip to Section D ➔ ➔

Linkage to or Re-engagement in HIV Medical Care
C2. Was the client provided navigation or other linkage services to facilitate linkage to or reengagement in HIV medical care? (X779)
○ No

○ Yes

○ Don’t know

C3. Did the client attend an HIV medical care appointment after session date? (X741)
○
○
○
○

No
Yes – confirmed
Yes – client/patient self-report
Don’t know

C4. If “Yes,” date attended (X741a): MM/DD/YYYY
Antiretroviral Treatment (ART)
C5. Did the client receive a prescription for HIV treatment (ART) after session date? (X762)
○
○
○
○

No
Yes – confirmed
Yes – client/patient self-report
Don’t know

C6. If “Yes,” how long after session date did the client receive an ART prescription? (X762a)

○ 8-30 days
○ ≥91 days

○ ≤ 7 days
○ 61-90 days

○ 31-60 days
○ Don’t know

HIV Partner Services (PS)
C7. Was the client's contact information provided to the health department for HIV partner services?
(X743)
○ No

○ Yes

○ Don’t know

C8. Was the client interviewed for HIV partner services? (X744)
○ No

○ Yes

○ Don’t know

C9. If “Yes,” date of interview (X744a): MM/DD/YYYY

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SECTION D. INTEGRATED TESTING AND DIAGNOSIS OF CO-INFECTIONS
(Complete for clients tested for HIV during this session, all settings)
D1. Was the client tested for co-infections? (X127)

○ No ○ Yes

○ Don’t know

➔ ➔ If “No” or “Don’t Know,” skip to Section E ➔ ➔
D2a. Was the client tested for syphilis? (X127a)

○ No ○ Yes
➔ ➔ If “No,” skip to D3a ➔ ➔

D2b. If yes, what was the result of the syphilis test? (X128a)
○ New Positive
○ Negative
○ Don’t know
➔ ➔ If “Negative” or “Don’t Know,” skip to D3a ➔ ➔
D2c. If new positive for syphilis, was the client referred/provided treatment? (X129a)
○ Referred to a provider
○ Provided treatment
○ No action
D3a. Was the client tested for gonorrhea? (X127b)

○ No ○ Yes
➔ ➔ If “No,” skip to D4a ➔ ➔

D3b. If yes, what was the result of the gonorrhea test? (X128b)
○ Positive
○ Negative
○ Don’t know
➔ ➔ If “Negative” or “Don’t Know,” skip to D4a ➔ ➔
D3c. If positive for gonorrhea, was the client referred/provided treatment? (X129b)
○ Referred to a provider
○ Provided treatment
○ No action
D4a. Was the client tested for chlamydia? (X127c)

○ No ○ Yes
➔ ➔ If “No” skip to D5a ➔ ➔

D4b. If yes, what was the result of the chlamydia test? (X128c)
○ Positive
○ Negative
○ Don’t know
➔ ➔ If “Negative” or “Don’t Know,” skip to D5a ➔ ➔
D4c. If positive for chlamydia, was the client referred/provided treatment? (X129c)
○ Referred to a provider
○ Provided treatment
○ No action

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D5a. Was the client tested for Hepatitis C? (X127d)

○ No ○ Yes
➔ ➔ If “No” skip to D6a ➔ ➔

D5b. If yes, what was the result of the Hepatitis C test? (X128d)
○ Positive
○ Negative
○ Don’t know
➔ ➔ If “Negative” or “Don’t Know,” skip to D6a ➔ ➔
D5c. If positive for Hepatitis C, was the client referred/provided treatment? (X129d)
○ Referred to a provider
○ Provided treatment
○ No action
D6a. Was the client tested for Hepatitis B? (X127e)

○ No ○ Yes
➔ ➔ If “No” skip to D7a ➔ ➔

D6b. If yes, what was the result of the Hepatitis B test? (X128e)
○ Positive
○ Negative
○ Don’t know
➔ ➔ If “Negative” or “Don’t Know,” skip to D7a ➔ ➔
D6c. If positive for Hepatitis B, was the client referred/provided treatment? (X129e)
○ Referred to a provider
○ Provided treatment
○ No action
D7a. Was the client tested for tuberculosis? (X127f)

○ No ○ Yes
➔ ➔ If “No” skip to D8a ➔ ➔

D7b. If yes, what was the result of the tuberculosis test? (X128f)
○ Positive
○ Negative
○ Don’t know
➔ ➔ If “Negative” or “Don’t Know,” skip to D8a ➔ ➔
D7c. If positive for tuberculosis, was the client referred/provided treatment? (X129f)
○ Referred to provider
○ Provided treatment
○ No action
D8a. Was the client tested for mpox? (X127g)

○ No ○ Yes
➔ ➔ If “No,” skip to D9a ➔ ➔

D8b. If yes, what was the result of the mpox test? (X128g)
○ Positive
○ Negative
○ Don’t know
➔ ➔ If “Negative” or “Don’t Know,” skip to D9a ➔ ➔
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D8c. If positive for mpox, was the client referred/provided treatment? (X129g)
○ Referred to a provider
○ Provided treatment
○ No action

○ No ○ Yes

D9a. Was the client tested for other infection/condition? (X127h)

➔➔ If “No,” skip to Section E ➔ ➔
D9b. If yes, what was the result of the test? (X128h)
○ Positive
○ Negative
○ Don’t know
➔ ➔ If “Negative” or “Don’t Know,” skip to Section E ➔ ➔
D9c. If positive for other infection/condition, was the client referred/provided treatment?
(X129h)
○ Referred to a provider
○ Provided treatment
○ No action
D9d. Specify what the other infection/condition the client was tested for (X141): _______________

SECTION E. PrEP/PEP SERVICES
PrEP AWARENESS AND USE (Complete for all clients, all settings)
E1. Has the client ever heard of PrEP before today? (H803)

○ No

○ Yes

E2. Was the client provided education/information on PrEP? (H804)

○ No

○ Yes

E3. Has the client ever used PrEP? (H805)
○ No – Never used PrEP
○ Yes – Used PrEP > 12 months ago
○ Yes – Used PrEP within ≤ 12 months
E4. Is the client currently taking PrEP? (X763)

➔ ➔ Skip to E5 ➔ ➔
➔ ➔ Skip to E5 ➔ ➔

○ No

○ Yes

➔ ➔ If ‘Yes,’ skip to E10 ➔➔

PrEP SCREENING AND FOLLOW-UP SERVICES (Complete for HIV-neg clients, all settings)
E5. Client can benefit from PrEP? (X764)
○ No
○ Yes – Self-interest
○ Yes – Provider recommendation

➔ ➔ If “No,” skip to E10 ➔ ➔

E6. Was client referred to a PrEP provider? (X780)
No

○ Yes – Referral accepted

○ Yes – Referral offer declined

E7. Was the client provided navigation for linkage services to a PrEP provider? (X765)
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○ Yes

○ No

○ Don’t know

○ Not needed

E8. Was the client linked to a PrEP provider? (X766)

○ No

○ Yes

E9. Was the client prescribed PrEP? (X767)

○ No

○ Yes

○ Not eligible

PEP AWARENESS (Complete for all clients, all settings)
E10. Has the client ever heard of PEP before today? (X768)

○ No

○ Yes

E11. Was the client provided education/information on PEP? (X769)

○ No

○ Yes

PEP SCREENING AND FOLLOW-UP SERVICES (Complete for HIV-neg clients, all settings)
E12. Client can benefit from PEP? (X770)
○ No

○ Yes

➔ ➔ If “No,” skip to Section F ➔ ➔

E13. Was the client prescribed PEP? (X771)

○ Yes

○ No

○ Not eligible

SECTION F. ESSENTIAL SUPPORT SERVICES
(Complete for all clients, all settings)
F1. Was the client screened for, referred to, or provided one or more of the essential support services
listed below? (X772)
○ No – Services were not available at this agency
○ No – Services were available, but client was not offered any service
(e.g., because services were limited to PWH only)
○ No – Services were available, but client refused all services
○ Yes – Client received one or more services (screening, referral, or assistance)
➔ ➔ If any “No,” skip to END ➔ ➔
F2a. Was the client screened for mental health service needs? (X773)
○ No – Not screened
○ Yes – Screened but no need identified
○ Yes – Screened and need was identified
➔ ➔ If “No – Not screened” or “Yes – Screened but no need identified,” skip to F3a ➔ ➔
F2b. If a mental health service need was identified, was the client referred to a provider or
provided the needed service? (X773a)
○
○
○
○
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Referral or service not offered
Referral or service offered but declined
Referred to a provider
Provided the needed service
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F3a. Was the client screened for substance use service needs? (X774)
○ No – Not screened
○ Yes – Screened but no need identified
○ Yes – Screened and need was identified
➔ ➔ If “No – Not screened” or “Yes – Screened but no need identified,” skip to F4a ➔ ➔
F3b. If a substance use service need was identified, was the client referred to a provider or
provided the needed service? (X774a)
○
○
○
○

Referral or service not offered
Referral or service offered but declined
Referred to a provider
Provided the needed service

F4a. If yes, was the client screened for housing service needs? (X775)
○ No – Not screened
○ Yes – Screened but no need identified
○ Yes – Screened and need was identified
➔ ➔ If “No – Not screened” or “Yes – Screened but no need identified,” skip to F5a ➔ ➔
F4b. If a housing service need was identified, was the client referred to a provider or
provided the needed service? (X775a)
○
○
○
○

Referral or service not offered
Referral or service offered but declined
Referred to a provider
Provided the needed service

F5a. If yes, was the client screened for health benefits or insurance navigation needs? (X776)
○ No – Not screened
○ Yes – Screened but no need identified
○ Yes – Screened and need was identified
➔ ➔ If “No – Not screened” or “Yes – Screened but no need identified,” skip to F6a ➔ ➔
F5b. If a health benefits or insurance navigation need was identified, was the client referred
to a provider or provided the needed service? (X776a)
○
○
○
○

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Referral or service not offered
Referral or service offered but declined
Referred to a provider
Provided the needed service

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F6a. If yes, was the client screened for social service needs? (X777)
○ No – Not screened
○ Yes – Screened but no need identified
○ Yes – Screened and need was identified
➔ ➔ If “No – Not screened” or “Yes – Screened but no need identified,” skip to F7a ➔ ➔
F6b. If a social service need was identified, was the client referred to a provider or provided
the needed service? (X777a)
○
○
○
○

Referral or service not offered
Referral or service offered but declined
Referred to a provider
Provided the needed service

F7a. If yes, was the client screened for harm reduction/syringe service needs? (X778)
○ No – Not screened
○ Yes – Screened but no need identified
○ Yes – Screened and need was identified
➔ ➔ If “No – Not screened” or “Yes – Screened but no need identified,” skip to END ➔ ➔
F7b. If a harm reduction/syringe service need was identified, was the client referred to a
provider or provided the needed service? (X778a)
○
○
○
○

Referral or service not offered
Referral or service offered but declined
Referred to a provider
Provided the needed service

END OF CLIENT-LEVEL DATA REQUIREMENTS

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