General instructions for completing the EvaluationWeb Directly Funded CBO Client-Level Data Collection Template This data collection template is provided to assist community-based organizations that receive direct CDC funding and collect National HIV Prevention Program Monitoring and Evaluation (NHME) Risk Reduction Activities (RRA) data. This template is not mandated for use and may be customized to fit the CBO s needs. Contact the NHME Service Center (1-855-374-7310 or NHMEservice@cdc.gov) to receive a version of this template that can be edited in Microsoft Publisher. The fields on this template reflect data requirements as described in the most current NHME Data Variable Set. Additional guidance can be found in the document NHME for CDC Directly Funded CBOs: Overview and Data Collection Guidance. This template is designed for direct data entry into EvaluationWeb. Detailed instructions for completing the EvaluationWeb Directly Funded CBO Client-Level Data Collection Template Section A Complete for all clients. Section B Complete each time a client enrolls in an intervention. There is space for up to two (2) interventions. Section C Enter the date a client first received condoms if program award includes direct funding for condom distribution as a structural intervention. Section D Complete when referrals are given to a client, as part of an intervention or independently. Section E Complete for all HIV-positive clients. For assistance with data reporting and submissions For technical assistance with EvaluationWeb, contact the HELP DESK at Luther Consulting (help@lutherconsulting.com or 1-866-517-6570 option #1). For questions about NHME data requirements or to receive a copy of NHME for CDC Directly Funded CBOs: Overview and Data Collection Guidance, contact the NHME Service Center (NHMEservice@cdc.gov or 1-855-374-7310). This data collection template is consistent with the OMB-approved information collection request #0920-0696 (expiration date: 03/31/2016). Version 1 Revised: 4/10/2014 2014 Luther Consul ng, LLC. All rights reserved. Page 1
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CBO Agency ID A28 SECTION A. DEMOGRAPHICS Date Demographics Collected G101 M M D D Y Y Y Y Race (select all that apply) G116 Year of Birth G112 Y Y Y Y American IN/AK Native Reason No Year of Birth CBO042 Declined to Answer Not Asked Asian Black or African American Native HI/Pac. Islander White Declined to Answer Don t Know Not Asked Ethnicity G114 Assigned Sex at Birth G123 Hispanic or Latino Not Hispanic or Latino Don t Know Declined to Answer Not Asked Male Female Declined to Answer SECTION B. ENROLLMENT IN HIV PREVENTION INTERVENTIONS INTERVENTION #1 Program Evidence Base H01b HIV Positive? CBO006 Date of Enrollment H07 M M D D Y Y Y Y No Yes Don t Know Program Announcement X137 Did the client report the following behaviors in the past 12 months? Completed Intervention? CBO003 No Yes Vaginal or anal sex with a male? CBO004 Current Gender Identity G124 No Yes Not Asked Male Female Transgender Male to Female Transgender Female to Male Transgender Unspecified Injection drug use? CBO005 No Yes Not Asked INTERVENTION #2 Program Evidence Base H01b HIV Positive? CBO006 Date of Enrollment H07 M M D D Y Y Y Y No Yes Don t Know Program Announcement X137 Did the client report the following behaviors in the past 12 months? Completed Intervention? CBO003 No Yes Vaginal or anal sex with a male? CBO004 Current Gender Identity G124 No Yes Not Asked Male Female Transgender Male to Female Transgender Female to Male Transgender Unspecified Injection drug use? CBO005 No Yes Not Asked SECTION C. CONDOM DISTRIBUTION (IF REQUIRED BY PROGRAM ANNOUNCEMENT) Date client was provided condoms CBO007 M M D D Y Y Y Y Version 1 Revised: 4/10/2014 2014 Luther Consul ng, LLC. All rights reserved. Page 3
SECTION D. REFERRALS Intervention Name H01a Program Evidence Base H01b Services Date of 1st Referral Date of 2nd Referral Date of 3rd Referral Basic Education Continuation and/or Completion Services CBO008 Behavioral Interventions for HIV Prevention CBO009 Dental Care CBO010 Employment and Readiness and Referral Programs CBO011 Food/Clothing/Other Basic Needs CBO012 HIV Testing CBO013 Housing Services CBO014 Insurance Enrollment CBO015 Mental Health Services Program CBO016 Post-Exposure Prophylaxis CBO017 Pre-Exposure Prophylaxis CBO018 Primary Health Care CBO019 Screening and/or Treatment for Hepatitis CBO020 Screening and/or Treatment for STDs CBO021 Screening and/or Treatment for Substance Abuse CBO022 Screening and/or Treatment for TB CBO023 Support Groups CBO024 Syringe Services Program CBO025 Transgender Transition Support Services CBO026 Other Services CBO028 (write in CBO027 if applicable) Version 1 Revised: 4/10/2014 2014 Luther Consul ng, LLC. All rights reserved. Page 4
SECTION E. REFERRALS AND LINKAGE SPECIFICALLY FOR POSITIVES HIV+ Med Referrals Date of Referral Date CBO Staff Initiated Discussion of Referral and Linkage to HIV Medical Care with Client CBO029 M M D D Y Y Y Y Date Client Received HIV-Positive Test Result CBO030 M M Y Y Y Y Reason No Date for HIV-Positive Test Result CBO031 Not Asked Declined to Answer Is the client currently in HIV medical care? CBO032 No Yes Not Asked Declined to Answer Was the client referred to HIV medical care? CBO033 Yes Date HIV medical care referral was made CBO034 M M D D Y Y Y Y No, referral offered, but client declined No, other reason Date the client attended 1st medical appointment CBO035 M M D D Y Y Y Y HIV+ Non-Med Referrals Date of 1st Referral Date of 2nd Referral Date of 3rd Referral Evidence-Based Linkage to Care Activity CBO036 HIV Medical Care (after unsuccessful initial attempt to refer and/or link to care, for re-engagement in care, or at client request) CBO037 Partner Services CBO038 Treatment adherence services, including adherence to ARV CBO039 Other Services CBO041 (write in CBO040) Version 1 Revised: 4/10/2014 2014 Luther Consul ng, LLC. All rights reserved. Page 5