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IMPACT DMVImprove Measurable Participation and Access to Care and TreatmentDemonstration Project ApplicationRFA# HAHSTA_IMPACTDMV_02.24.17ATTACHMENTS(WORD VERSION)Appendix A – Applicant ProfileAppendix B – Work Plan TemplateAppendix C – Budget TemplateAppendix D –Assurances, Certifications & DisclosuresAppendix E - Core Services and Client Flow ChartAppendix F – Client Data Collection Tool APPENDIX A - Applicant ProfileApplicant Name: ______________________________________________________________TYPE OF ORGANIZATIONSmall Business________ Non-Profit Organizations ________Other _________Contact Person: _______________________________________________________________Office Address: ________________________________________________________________ __________________________________________________________________________________________________________________________________Telephone:__________________________________________________________________E-Mail Address: ______________________________________________________________Program Description: ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________DUNS#:__________________________________Program Area(s): __________________________________BUDGETTotal Funds Requested:$________________Agency: Program Period: Grant #: Submission Date:Focus Population /Service:Submitted by:Total Budget $Telephone #GOAL 1:Measurable Objectives/Activities:Process Objective #1:[Example: By December 31, 2017, provide 2,500 face-to-face outreach contacts for 500 unduplicated injection drug users in Wards 5 & 6]2562225217805SAMPLE00SAMPLEKey activities needed to meet this objective:Start Date/s:Completion Date/s:Key Personnel (Title)Process Objective #2:Key activities needed to meet this objective:Start Dates:Completion Dates:Key Personnel (Title)Process Objective #3:Key activities needed to meet this objective:Start Dates:Completion Dates:Key Personnel (Title)-523875-567055APPENDIX B: WORK PLAN00APPENDIX B: WORK PLAN-588010-692785APPENDIX C - Categorical Budget and Budget Narrative00APPENDIX C - Categorical Budget and Budget NarrativeProvider NameService Area Name?Service Area Budget Summary??ProposedBudget????Salaries & Wages Subtotal??????Fringe Benefits Subtotal??????Consultants & Experts Subtotal??????Occupancy Subtotal???????Travel & Transportation Subtotal??????Supplies & Minor Equipment Subtotal??????Capital Equipment Subtotal??????Client Costs Subtotal???????Communications Subtotal??????Other Direct Costs Subtotal??????Administrative Cost Subtotal10%??????Advance Subtotal???TOTAL? - Personnel Schedule?????????Option No. 1?Option No. 2???PositionSiteAnnualFTEHourlyHoursMonthlyNo.BudgetTitle?Salary?WageperSalary orofAmount?????MonthWageMo.?????????????????????????????????????????????????????????????????????????TOTAL?????????????????Consultant/Contractual???????Item?Unit?UnitCostNumber?Budget?????????????? - ??????????????????TOTAL??????? - ???Occupancy Schedule???????FacilitySiteUnit?UnitCostNumber?Budget?????????Rent??????? - ??Utilities (Gas/Electric/Water)??????? - ?????????TOTAL??????? - Travel / Transportation ScheduleItem?Unit?UnitCostNumber?Budget????????????????? - ??????????????????TOTAL??????? - Supplies ????????ItemSiteUnit?UnitCostNumber?Budget????????????????? - ?????????TOTAL??????? - Capital Equipment Schedule???????ItemSiteUnit?UnitCostNumber?Budget???????????????????????????TOTAL????????Client Cost Schedule???????ItemSiteUnit?UnitCostNumber?Budget????????????????? - ???????????????TOTAL??????? - Communications ScheduleItemSiteUnit?UnitCostNumber?Budget????????????????? - ????????????????? - ???????????????????????????TOTAL??????? - Other Direct Costs ScheduleItem??UnitUnitCostNumber?Budget????????????????????????????????????TOTAL?????????????????Indirect Costs???????????????????????????????????TOTAL????????APPENDIX D. APPLICANT / GRANTEE ASSURANCES, CERTIFICATIONS & DISCLOSURESThis section includes certifications, assurances and disclosures made by the authorized representative of the Applicant/Grantee organization. These assurances and certifications reflect requirements for recipients of local and pass-through federal funding.A. Applicant/Grantee RepresentationsThe Applicant/Grantee has provided the individuals, by name, title, address, and phone number who are authorized to negotiate with the Department of Health on behalf of the organization; The Applicant/Grantee is able to maintain adequate files and records and can and will meet all reporting requirements;All fiscal records are kept in accordance with Generally Accepted Accounting Principles (GAAP) and account for all funds, tangible assets, revenue, and expenditures whatsoever; all fiscal records are accurate, complete and current at all times; and these records will be made available for audit and inspection as required;The Applicant/Grantee is current on payment of all federal and District taxes, including Unemployment Insurance taxes and Workers’ Compensation premiums. This statement of certification shall be accompanied by a certificate from the District of Columbia OTR stating that the entity has complied with the filing requirements of District of Columbia tax laws and is current on all payment obligations to the District of Columbia, or is in compliance with any payment agreement with the Office of Tax and Revenue; (attach)The Applicant/Grantee has the administrative and financial capability to provide and manage the proposed services and ensure an adequate administrative, performance and audit trail; If required by DOH, the Applicant/Grantee is able to secure a bond, in an amount not less than the total amount of the funds awarded, against losses of money and other property caused by a fraudulent or dishonest act committed by Applicant/Grantee or any of its employees, board members, officers, partners, shareholders, or trainees;The Applicant/Grantee is not proposed for debarment or presently debarred, suspended, or declared ineligible, as required by Executive Order 12549, “Debarment and Suspension,” and implemented by 2 CFR 180, for prospective participants in primary covered transactions and is not proposed for debarment or presently debarred as a result of any actions by the District of Columbia Contract Appeals Board, the Office of Contracting and Procurement, or any other District contract regulating Agency; The Applicant/Grantee either has the financial resources and technical expertise necessary for the production, construction, equipment and facilities adequate to perform the grant or subgrant, or the ability to obtain them;The Applicant/Grantee has the ability to comply with the required or proposed delivery or performance schedule, taking into consideration all existing and reasonably expected commercial and governmental business commitments;The Applicant/Grantee has a satisfactory record of performing similar activities as detailed in the award or, if the grant award is intended to encourage the development and support of organizations without significant previous experience, has otherwise established that it has the skills and resources necessary to perform the services required by this Grant.The Applicant/Grantee has a satisfactory record of integrity and business ethics;The Applicant/Grantee either has the necessary organization, experience, accounting and operational controls, and technical skills to implement the grant, or the ability to obtain them;The Applicant/Grantee is in compliance with the applicable District licensing and tax laws and regulations;The Applicant/Grantee is in compliance with the Drug-Free Workplace Act and any regulations promulgated thereunder; andThe Applicant/Grantee meets all other qualifications and eligibility criteria necessary to receive an award; andThe Applicant/Grantee agrees to indemnify, defend and hold harmless the Government of the District of Columbia and its authorized officers, employees, agents and volunteers from any and all claims, actions, losses, damages, and/or liability arising out of or related to this grant including the acts, errors or omissions of any person and for any costs or expenses incurred by the District on account of any claim therefrom, except where such indemnification is prohibited by law. B. Federal Assurances and CertificationsThe Applicant/Grantee shall comply with all applicable District and federal statutes and regulations, including, but not limited to, the following: The Americans with Disabilities Act of 1990, Pub. L. 101-336, July 26, 1990; 104 Stat. 327 (42 U.S.C. 12101 et seq.);Rehabilitation Act of 1973, Pub. L. 93-112, Sept. 26, 1973; 87 Stat. 355 (29 U.S.C. 701 et seq.);The Hatch Act, ch. 314, 24 Stat. 440 (7 U.S.C. 361a et seq.);The Fair Labor Standards Act, ch. 676, 52 Stat. 1060 (29 U.S.C.201 et seq.);The Clean Air Act (Subgrants over $100,000), Pub. L. 108-201, February 24, 2004; 42 USC ch. 85 et.seq.);The Occupational Safety and Health Act of 1970, Pub. L. 91-596, Dec. 29, 1970; 84 Stat. 1590 (26 U.S.C. 651 et.seq.);The Hobbs Act (Anti-Corruption), ch. 537, 60 Stat. 420 (see 18 U.S.C. § 1951);Equal Pay Act of 1963, Pub. L. 88-38, June 10, 1963; 77 Stat.56 (29 U.S.C. 201);Age Discrimination Act of 1975, Pub. L. 94-135, Nov. 28, 1975; 89 Stat. 728 (42 U.S.C. 6101 et. seq.);Age Discrimination in Employment Act, Pub. L. 90-202, Dec. 15, 1967; 81 Stat. 602 (29 U.S.C. 621 et. seq.);Military Selective Service Act of 1973;Title IX of the Education Amendments of 1972, Pub. L. 92-318, June 23, 1972; 86 Stat. 235, (20 U.S.C. 1001);Immigration Reform and Control Act of 1986, Pub. L. 99-603, Nov 6, 1986; 100 Stat. 3359, (8 U.S.C. 1101);Executive Order 12459 (Debarment, Suspension and Exclusion);Medical Leave Act of 1993, Pub. L. 103-3, Feb. 5, 1993, 107 Stat. 6 (5 U.S.C. 6381 et seq.);Drug Free Workplace Act of 1988, Pub. L. 100-690, 102 Stat. 4304 (41 U.S.C.) to include the following requirements:Publish a statement notifying employees that the unlawful manufacture, distribution, dispensing, possession or use of a controlled substance is prohibited in the Applicant/Grantee's workplace and specifying the actions that will be taken against employees for violations of such prohibition;Establish a drug-free awareness program to inform employees about: The dangers of drug abuse in the workplace;The Applicant/Grantee's policy of maintaining a drug-free workplace;Any available drug counseling, rehabilitation, and employee assistance programs; andThe penalties that may be imposed upon employees for drug abuse violations occurring in the workplace; and (3)Provide all employees engaged in performance of the grant with a copy of the statement required by the law; Assurance of Nondiscrimination and Equal Opportunity, found in 29 CFR 34.20;District of Columbia Human Rights Act of 1977 (D.C. Official Code § 2-1401.01 et seq.);Title VI of the Civil Rights Act of 1964;District of Columbia Language Access Act of 2004, DC Law 15 - 414 (D.C. Official Code § 2-1931 et seq.); Lobbying Disclosure Act of 1995, Pub. L. 104-65, Dec 19, 1995; 109 Stat. 693, (31 U.S.C. 1352); andChild and Youth, Safety and Health Omnibus Amendment Act of 2004, effective April 13, 2005 (D.C. Law §15-353; D.C. Official Code § 4-1501.01 et seq.)(CYSHA). In accordance with the CYSHA any person who may, pursuant to the grant, potentially work directly with any child (meaning a person younger than age thirteen (13)), or any youth (meaning a person between the ages of thirteen (13) and seventeen (17) years, inclusive) shall complete a background check that meets the requirements of the District's Department of Human Resources and HIPAA.C.Mandatory DisclosuresThe Applicant/Grantee certifies that the information disclosed in the table below is true at the time of submission of the application for funding and at the time of award if funded. If the information changes, the Grantee shall notify the Grant Administrator within 24 hours of the change in status. A duly authorized representative must sign the disclosure certification Applicant/Grantee Mandatory Disclosures Per OMB 2 CFR §200.501– any recipient that expends $750,000 or more in federal funds within the recipient’s last fiscal, must have an annual audit conducted by a third – party. In the Applicant/Grantee’s last fiscal year, were you required to conduct a third-party audit?YESNOCovered Entity Disclosure During the two-year period preceding the execution of the attached Agreement, were any principals or key personnel of the Applicant/Grantee / Recipient organization or any of its agents who will participate directly, extensively and substantially in the request for funding (i.e. application), pre-award negotiation or the administration or management of the funding, nor any agent of the above, is or will be a candidate for public office or a contributor to a campaign of a person who is a candidate for public office, as prohibited by local law.YESNOExecutive Compensation: For an award issued at $25,000 or above, do Applicant/Grantee’s top five executives do not receive more than 80% of their annual gross revenues from the federal government, Applicant/Grantee’s revenues are greater than $25 million dollars annually AND compensation information is not already available through reporting to the Security and Exchange Commission.If No, the Applicant, if funded shall provide the names and salaries of the top five executives, per the requirements of the Federal Funding Accountability and Transparency Act – P.L. 109-282.YESNOThe Applicant/Grantee organization has a federally-negotiated Indirect Cost Rate Agreement. If yes, insert issue date for the IDCR: ___________ If yes, insert the name of the cognizant federal agency? _____________YESNONo key personnel or agent of the Applicant/Grantee organization who will participate directly, extensively and substantially in the request for funding (i.e. application), pre-award negotiation or the administration or management of the funding is currently in violation of federal and local criminal laws involving fraud, bribery or gratuity violations potentially affecting the DOH award.YESNOACCEPTANCE OF ASSURANCES, CERTIFICATIONS AND DISCLOSURESI am authorized to submit this application for funding and if considered for funding by DOH, to negotiate and accept terms of Agreement on behalf of the Applicant/Grantee organization; and I have read and accept the terms, requirements and conditions outlined in all sections of the RFA, and understand that the acceptance will be incorporated by reference into any agreements with the Department of Health, if funded; and I, as the authorized representative of the Grantee organization, certify that to the best of my knowledge the information disclosed in the Table: Mandatory Disclosures is accurate and true as of the date of the submission of the application for funding or at the time of issuance of award, whichever is the latter.Sign:Date:NAME: INSERT NAMETITLE: INSERT TITLE AGENCY NAME: APPENDIX E– Core Services and Client Flow ChartPrevention and Care Core ServicesPrevention HIV testing services that use 4th generation HIV tests preferably (rapid 4th generation would be allowed with a plan to move to lab base testing)Assessment of indications for PrEP and nPEPProvision of PrEP and nPEPAdherence interventions for PrEP and nPEPImmediate linkage to care, ARV treatment, and partner services for those diagnosed with acute HIV infectionExpedient linkage to care, ARV treatment, and partner services for those diagnosed with established HIV infectionSTD screening and treatmentBehavioral risk reduction interventionsScreening for behavioral health and social services needsLinkage to behavioral health and social servicesNavigators to assist accessing HIV prevention and behavioral health and social servicesNavigators to assist enrollment in a health planEmployment/Workforce DevelopmentCare Navigation to HIV primary care, including ARV treatmentRetention interventionsRe-engagement interventionsAdherence interventionsSTD screening and treatmentBehavioral risk reduction interventionsScreening patients for behavioral health and social services needsLinkage to behavioral health and social servicesNavigators to assist linking to care and accessing behavioral health and social servicesNavigators to assist enrollment in a health planEmployment/workforce development services*Employment service/workforce development has been added to both the prevention and care list as a key component to impacting health outcomes. These are not in the original list of CDC core services.APPENDIX F – IMPACT DMV Data FormFacility Information Facility NamePerson Completing FormA. Demographics (static section)1. Client ID2. First Name3. Last Name4. Date of Birth____/____/_______5. Sex at birth Male Female Intersex6. Current Gender Male Female Transgender – FTM Transgender – MTF Intersex Gender queer Questioning Other 7. Ethnicity Hispanic or Latino Non-Hispanic Prefer not to answer8. Race (check all that apply) American Indian/Alaska Native Asian Black/African American Native Hawaiian/Other Pacific Islander White Multirace/Other Prefer not to answer 9. State 10. Vital Status Alive Dead Unknown Date of Death ____/_____/_______ B. Client History (static section)11. Vaginal sex with female Yes No UnknownIf Yes, answer 11a-11c about their partner(s)a. Without using a Condom Yes No Unknownb. Who is an IDU Yes No Unknownc. Who is HIV + Yes No Unknown12. Anal sex with female Yes No UnknownIf Yes, answer 12a-12c about their partner(s)a. Without using a Condom Yes No Unknownb. Who is an IDU Yes No Unknownc. Who is HIV + Yes No Unknown13. Anal sex with male Yes No UnknownIf Yes, answer 13a-13c about their partner(sa. Without using a Condom Yes No Unknownb. Who is an IDU Yes No Unknownc. Who is HIV + Yes No Unknown14. Vaginal sex with a transgendered individual Yes No UnknownIf Yes, answer 14a-14c about their partner(s)a. Without using a Condom Yes No Unknownb. Who is an IDU Yes No Unknownc. Who is HIV + Yes No Unknown15. Anal sex with a transgendered individual Yes No UnknownIf Yes, answer 15a-15c about their partner(s)a. Without using a Condom Yes No Unknownb. Who is an IDU Yes No Unknownc. Who is HIV + Yes No UnknownFemale or Transgender-MTF Clients Only: 16. Vaginal sex with Male Yes No UnknownIf Yes, answer 16a-16c about their partner(s)a. Without using a Condom Yes No Unknownb. Who is an IDU Yes No Unknownc. Who is HIV + Yes No Unknown17. Vaginal sex with an MSM Yes No Unknown18. Anal sex with an MSM Yes No UnknownC. Service Date (repeatable section)19. Service Visit Date____/_____/_______ (add new date and repeatable sections appear)D. Medical Care and Lab Testing (repeatable section)20. HIV Test Date____/_____/_______What test technology was used? Conventional 4th generation lab- based Rapid 4th generation NAAT/RNA testing Other (please specify)HIV Test Result Positive/Reactive Negative Indeterminate Invalid No Result21. HIV Status Newly diagnosed Previously diagnosed, Never in care Previously diagnosed, previously in care but lost to follow-up HIV negative22. If HIV positive: Was the client referred to an HIV care provider? Internal Provider External Provider NoIf not referred: Why wasn’t the client referred? Client already in care Client declined careIf referred: Referral date ____/_____/_______If referred: Appointment date____/_____/_______If external provider: Where were they referred?If referred: Did the client attend the appointment? Yes NoIf client did not attend appt: Reason for missed appointment:23. Is this a data to care client? Yes NoIf Yes: Date identified as not in care ____/_____/_______ If Yes: Date contacted by program staff ____/_____/_______If Yes: Where were they referred?If Yes: Appointment date____/_____/_______If Yes: Did the client attend the appointment? Yes NoIf client did not attend appt: Reason for missed appointment:24. Is this client re-engaging in care after being out of care for more than 12 months? Yes No Unknown25. Was the client prescribed ARVs? Yes NoIf Yes: Date ARV prescribed ____/_____/_______If Yes: Was medication adherence support provided? Yes No Declined N/AE. STD Services (repeatable section)26. Was the client screened for STDs? Yes No Unknown If Yes: Date screened ____/_____/_______If Yes: Was the client screened for gonorrhea? Yes No Unknown If Yes: What was the result? Positive Negative UnknownIf positive: Was the client referred to medical care? Internal Provider External Provider No If not referred: Why wasn’t the client referred? Client already in care Client declined careIf referred: Referral Date ____/_____/_______If referred: Appointment Date ____/_____/_______If external provider: Where were they referred?If referred: Did the client attend the appointment? Yes NoIf client did not attend appt: Reason for missed appointment:If positive for gonorrhea: Were they treated? Yes No Unknown Was the client screened for syphilis? Yes No Unknown If Yes: What was the result? Positive Negative UnknownIf positive: Was the client referred to medical care? Internal Provider External Provider NoIf not referred: Why wasn’t the client referred? Client already in care Client declined careIf referred: Referral Date____/_____/_______If referred: Appointment Date____/_____/_______If external provider: Where were they referred? If referred: Did the client attend the appointment? Yes NoIf client did not attend the appt: Reason for missed appointment:If positive for syphilis: Were they treated? Yes No UnknownWas the client screened for chlamydia? Yes No UnknownIf Yes: What was the result? Positive Negative UnknownIf positive: Was the client referred to medical care? Internal Provider External Provider NoIf not referred: Why wasn’t the client referred? Client already in care Client declined careIf referred: Referral Date____/_____/_______If referred: Appointment Date____/_____/_______ab. If external provider: Where were they referred?ac. If referred: Did the client attend the appointment? Yes Noad. If client did not attend the appointment: Reason for missed appointment:ae. If positive for chlamydia: Were they treated? Yes No Unknown27. Are you requesting partner services? Yes NoIf Yes: Partner Services Interview Date____/_____/_______If Yes: Number of partners named by person:F. Behavioral Health and Social Services (repeatable section)28. Was the client screened for mental health issues? Yes NoIf Yes: Was a mental health services need identified? Yes NoIf Yes: Was the client referred to mental health services? Internal Provider External Provider NoIf Yes: Referral Date ___/_____/_______If referred: Appointment Date____/_____/_______If external provider: Where were they referred? If not referred: Why wasn’t the client referred? Client already in care Client declined careIf referred: Did the client attend the appointment? Yes NoIf client did not attend the appt: Reason for missed appointment:If need identified: What services were provided to the client? (select all that apply) individual counseling group counseling psychiatrist prescribed medication Other (please specify)29. Was the client screened for substance abuse issues? Yes NoIf Yes: Was a substance abuse need identified? Yes NoIf Yes: Was the client referred to substance abuse services? Internal Provider External Provider No If not referred: Why wasn’t the client referred? Client already in care Client declined careIf referred: Referral Date ____/_____/_______If referred: Appointment Date____/_____/_______If external provider: Where were they referred?If referred: Did the client attend the appointment? Yes NoIf client did not attend the appt: Reason for missed appointment:If need identified: What services were provided to the client? (select all that apply) alcoholics anonymous narcotics anonymous individual counseling needle exchange inpatient services outpatient services recovery coaching & mentoring Other (please specify)30. Was the client screened for housing services issues? Yes NoIf Yes: Was a housing services need identified? Yes NoIf Yes: Was the client referred to housing services? Internal Provider External Provider No If not referred: Why wasn’t the client referred? Client already in care Client declined careIf referred: Referral Date ____/_____/_______If referred: Appointment Date____/_____/_______If external provider: Where were they referred?If referred: Did the client attend the appointment? Yes NoIf client did not attend the appt: Reason for missed appointment:If need identified: What services were provided to the client? (select all that apply) sponsor based assistance tenant based rental assistance short term short term mortgage assistance short term utility assistance transitional facility-based housing emergency facility-based housing housing information services rental deposit eligibility list None31. Was the client screened for education assistance needs? Yes NoIf Yes: Was an education assistance need identified? Yes NoIf Yes: Was the client referred to education assistance services? Internal Provider External Provider NoIf not referred: Why wasn’t the client referred? Client already in care Client declined careIf referred: Referral Date____/_____/_______If referred: Appointment Date ____/_____/_______If external provider: Where were they referred?If referred: Did the client attend the appointment? Yes NoIf client did not attend the appt: Reason for missed appointment:If need identified: What services were provided to the client? (select all that apply) high school equivalency vocational school adult basic education college Other (please specify)32. Was the client screened for employment and job training needs? Yes No If Yes: Was an employment and job training need identified? Yes NoIf Y: Was the client referred to employment/job training services? Internal Provider External Provider NoIf not referred: Why wasn’t the client referred? Client already in care Client declined care If referred: Referral Date____/_____/_______If referred: Appointment Date____/_____/_______If external provider: Where were they referred?If referred: Did the client attend the appointment? Yes NoIf client did not attend the appt: Reason for missed appointment:If need identified: What services were provided to the client? (select all that apply) job readiness skills job corps short-term training certifications apprenticeships internships professional development licensing Other (please specify)33. Was the client screened for transportation needs? Yes No If Yes: Was a transportation need identified? Yes NoIf Yes: Was the client referred to transportation services? Internal Provider External Provider NoIf not referred: Why wasn’t the client referred? Client already in care Client declined care If referred: Referral Date____/_____/_______If referred: Appointment Date____/_____/_______If external provider: Where were they referred? If referred: Did the client attend the appointment? Yes NoIf need identified: Please select which transportation services the client was linked to: subsidized SmarTrip card ride share (uber, lyft, etc.) short term car payment assistance transportation information services picked up/ dropped off for appointments Other (please specify) 34. Was the client screened for health insurance? Yes No N/AIf Yes: What health insurance does the client have? Medicaid Medicare DC Alliance Private Other public Self-pay Other None UnknownIf Yes: Was a need for health insurance identified? (i.e. uninsured, underinsured, need financial assistance) Yes No If Yes: Was the client referred to a health insurance navigator? Yes No If Yes: Referral Date____/_____/_______If Yes: Was the client linked to or helped by a navigator to get health insurance? Yes No If need identified: Was the client enrolled in health insurance? Yes NoIf Yes: Date enrolled in health insurance ____/_____/_______35. Did the client receive behavioral risk reduction counseling? Yes No N/Aa. If Yes: Date received behavioral risk reduction counseling ____/_____/_______36. Was the client provided linkage or re-engagement intervention services? Yes No Declined Unknown If Yes: Date of linkage or re-engagement intervention services ____/_____/_______Was the client provided retention intervention services? Yes No Declined Unknown If Yes: Date of retention intervention services ____/_____/_______G. PrEP and nPEP (HIV-Negative Clients Only) (repeatable section)37. Was the client screened for PrEP? Yes NoIf Yes: Date screened for PrEP ____/_____/_______If Yes: Was the client eligible for PrEP? Yes NoIf Yes: Was the client referred to a PrEP provider? Internal provider External provider NoIf not referred: Why wasn’t the client referred? Client already in care Client declined care If referred: Referral date____/_____/_______If referred: Appointment date____/_____/_______If external provider: Where was the client referred? If referred: Did the client attend this appointment? Yes NoIf referred: Why were they interested in taking PrEP? (check all that apply) Occasional HIV positive partners Reduce my risk of getting HIV Don’t want to use condoms with my partners Transitioning form nPEP Fear of getting HIV In a sero-discordant relationship Other (please specify)If attended appt: Was the client prescribed PrEP? Yes NoIf Yes: Date prescribed PrEP ____/_____/_______If prescribed: Was the client provided PrEP adherence support? Yes NoIf prescribed: Did the client stop taking PrEP? Yes NoIf Yes: Date stopped PreP: ____/_____/_______If Yes: Why did they stop PrEP? (select all that apply) No longer at risk HIV Positive Side effects Lost health insurance Provider no longer available Did not fill prescriptions Cannot remember to take pills Stigma No longer in sero-discordant relationship Other (please specify)If prescribed: Which follow-up appointments did the client attend? (select all that apply) 3 months 6 months 9 months 12 months 15 months 18 months 21 months 24 months 27 months 30 months 33 months 36 months38. Was the client screened for nPEP? Yes NoDate screened for nPEP ____/_____/_______If Yes: Was the client eligible for nPEP? Yes NoIf Yes: Was the client referred to a nPEP provider? Internal External NoIf not referred: Why wasn’t the client referred? Client already in care Client declined careIf referred: Referral date ____/_____/_______If referred: Appointment date____/_____/_______If external provider: Where was the client referred?If referred: Did the client attend this appointment? Yes NoIf Yes: Was the client prescribed nPEP? Yes NoIf Yes: Date prescribed nPEP: ____/_____/_______If prescribed: Was the client provided nPEP adherence support? Yes NoIf prescribed: Did the client complete the 28 day nPEP regimen? Yes NoIf No: Date stopped nPEP: ____/_____/_______If prescribed: Number of days missed of 28-day nPEP course: If No: Why did they stop nPEP? HIV Positive Side effects Cannot afford Lost health insurance Provider no longer available Did not fill prescriptions Cannot remember to take pills Stigma Other (please specify) ................
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