2. Address 1

3. Address 2

4. City

5. State AL  AK  AS  AZ  AR  CA  CO  CT  DE  DC  FM  FL  GA  GU  HI  ID  IN  IA  KS  KY  LA  ME  MH  MD  MA  MI  MN  MS  MO  MT  NE  NV  NH  NJ  NM  NY  NC  ND  MP  OH  OK  OR  PW  PA  PR  RI  SC  SD  TN  TX  UT  VT  VI  VA  WV  WI  WY 

6. ZIP code

7. Phone number

Extension

8. Fax number

9. Website

10. 2010 UDS number

11. Year established

12. Total number of delivery sites

13. Location(s) (select all that apply) Urban  Rural  Suburban 

15b. Title  *

15c. E-mail address  *

15d. Telephone number  *

16b. Specialist care physicians

16c. Nurse practitioners

16d. Physician assistants

17. Total number of annual patient encounters

18. Total number of annual patients

19. Average number of visits per provider

21b. Native Hawaiian or Other Pacific Islander

21c. Black/African American

21d. American Indian/Alaska Native

21e. White/Caucasian

21f. More than 1 race

22b. Regular Medicaid

22c. CHIP Medicaid

22d. Medicare

22e. Other public insurance non-CHIP

22f. Other public insurance CHIP

22g. Private insurance

23b. Email address

23c. Phone number

23d. Years in position

24b. Title

24c. Email address

24d. Phone number

25b. Email address

25c. Phone number

25d. Years in position

26b. Email address

26c. Phone number

26d. Years in position

27b. Email address

27c. Phone number

27d. Years in position

28b. Email address

28c. Phone number

28d. Years in position

29b. Email address

29c. Phone number

29d. Years in position

32. If rapid HIV tests are used to screen patients, what is the source of the test kits? (select all that apply) State/local health department  Grant  No extra funding  Rapid HIV test kits are not used  Other: please specify below 

Other, specify

33. What patient-level data is collected for each patient offered HIV testing as part of routine primary care? (select all that apply) Accept/decline test  Reason for decline  Previous testing history  Test result  Linkage to care for positives  Demographic information  Risk factors  Risk reduction plan for negatives  None 

35. Of patients reported in question 34, how many received 2 or more visits with a provider (MD, DO, PA, NP) at least three months apart?

Select here if patient number is unknown

36. Of patients reported in question 34, how many received HIV risk counseling?

Select here if patient number is unknown

37. Of patients reported in question 34, how many received 2 or more CD4 T-cell counts performed at least three months apart?

Select here if patient number is unknown

38. What HIV care and treatment services does your health center organization currently provide? (select all that apply) Monitoring HIV progression for prescribing medications for OI prophylaxis  Initiating first line antiretroviral (ARV)  Genotype/phenotype testing and interpretation  Prescribe second-line ARV  Prescribe ARV therapy for multi-drug resistant patients 

Other, specify

38b. Initiating first line antiretroviral (ARV) treatment? (select all that apply) Staff ID/HIV Specialist   Staff Primary Care Primary Care Provider  Contracted HIV Provider (in house)  Other 

Other, specify

38c. Genotype/Phenotype testing and interpretation? (select all that apply) Staff ID/HIV Specialist   Staff Primary Care Primary Care Provider  Contracted HIV Provider (in house)  Other 

Other, specify

38d. Prescribe second-line ARVs? (select all that apply) Staff ID/HIV Specialist   Staff Primary Care Primary Care Provider  Contracted HIV Provider (in house)  Other 

Other, specify

38e. Prescribe ARV therapy for multi-drug resistant patients? (select all that apply) Staff ID/HIV Specialist   Staff Primary Care Primary Care Provider  Contracted HIV Provider (in house)  Other 

Other, specify

39. How does your health center organization collect and report HIV data? (select all that apply) EHR  Registry  Practice Management System  Manually  Other - please specify below 

Other, specify

40. How are HIV services funded? (select all that apply) Ryan White Part A sub-contract   Ryan White Part B sub-contract  Ryan White Part C sub-contract  Ryan White Part D sub-contract  County or City funding  State general funding  CDC grant or cooperative agreement  SAMHSA grant  Private funding/donations  Third party billing  Other - please specify below 

Other, specify

41. To whom do you report HIV data? (select all that apply) State or Local Health Department  Health Center Board of Directors  Internal Quality Improvement Committee  AIDS Education and Training Center (AETC)  Infectious Disease Clinic  Other - please specify below 

Other, specify

42. Which HIV performance/quality measures are included in your health center's Quality Improvement Plan? (select all that apply CD4 count  Viral load  Medical visits in a year  Antiretroviral Therapy (ART)  Pneumocystis Carinii Pneumonia (PCP) Prophylaxis  Immunizations  STI screening  Pap smears  None 

Specify year recognized

Specify level attained

44. If not, does your health center organization plan to apply for Patient Centered Medical Home recognition? (select one)  Yes, through NCQA
   Yes, through URAC
   Yes, through Joint Commission
   Yes, through AAAHC
   Yes, through the state
   No but plan to apply in the next 18 months
   No and have no current plans to apply 

45. Please estimate what percent of your total patients are assigned to a primary care provider

Select here if unknown

46. What is the estimated percentage of appointments left open for same day access

Select here if unknown

47. What is the estimated percentage of total claims rejected?

Select here if unknown

Adoption date (go-live date)

49. If yes, what EHR product does your health center organization use? (select all that apply) Allscripts  NextGen  Sage  eClinical Works  EHS  GE Centricity  Other (specify below) 

Other, specify

51. What additional activities will your health center be undergoing during 2012? (select all that apply) ER diversion program  New capital projects  Oral health expansion  Behavioral health expansion  New access points expansion  Open access  Layoffs  Closure  Consolidation  Loss of funding  Other (please specify below)  

Other, specify

53. Please describe past training or technical assistance your health center has received from a regional or national AETC.

54. Please indicate any current or future training or technical assistance plans you have with a regional or national AETC.

56. Partnerships with local correctional facilities (jails, juvenile detention).

57. Behavioral health programs (including in-house or partnerships).

58. Partnerships with local emergency departments in HIV testing or linkage to care.

59. Existing partnerships to support care and treatment of newly diagnosed HIV patients.

61. Describe your health center organization’s current process for managing HIV positive patients.

Number 2

Number 3

63. Describe why your health center is interested in applying for this HIV capacity building opportunity. Please include description of need for these services in the community your health center serves. *Response limited to 150 words.