Project Clinic Characteristics Form

Integrating Community Pharmacists and Clinical Sites for Patient-Centered HIV Care

Att 3_Project Clinic Characteristics form

Project Clinic Characteristics Form

OMB: 0920-1019

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Attachment 3 Clinic Project ID: __________



Form Approved

OMB No: 0920-XXXX

Exp. Date: XX/XX/XXXX







Project Clinic Characteristics Form











Public reporting burden of this collection of information is estimated to average 30 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; Attn: OMB-PRA (0920-New)







Project Clinic Characteristics form

Please provide the following information for the 12 month calendar year

Location

City/Town: _____________

State: _____________

Type of clinic (check all that apply):

□ public

□ private

□ primary care clinic

□ ID or HIV specialty clinic

For public clinic (check all that apply):

□ Federally Qualified Health Center

□ Community Health Center

□ Ryan White clinic

□ other __________

For private clinic (check all that apply):

□ managed care clinic

□ academic medical center clinic

□ non-academic medical center clinic

□ retail clinic

□ other __________

Location:

□ urban

□ suburban

□ rural

Year (that the following information covers):

□ 2012

□ 2013

□ 2014

□ 2015

□ 2016

Total number of patients at the clinic? _______

Total number of patients by sex:

Male ________

Female _________

Total number of patients by race:

American Indian/Alaska Native ________

Asian ________

Black/African American ________

Native Hawaiian/Pacific Islander ________

White _______

Unknown ________

Bi-racial ________

Other: ­­­­_______

Total number of patients by ethnicity:

Hispanic/Latino ________

Not Hispanic/Latino _______

Unknown ________

Total number of patients at the clinic that are HIV positive: _________

Number of insured HIV positive patients:

_________

Number of insured non-HIV positive patients:

_________

Of the insured HIV positive patients, the number of insured patients by insurance type:

Private insurance _________

Medicaid _________

Medicare __________

Tricare _________

Other _________

Unknown __________

Number of total clinic visits (for all patients): __________

Number of individual patient visits for HIV-positive patients: __________

Number of individual patient visits for HIV positive patients

that were kept: __________

Number of individual patient visits for non-HIV-positive patients: __________

Number of individual patient visits for non-HIV positive patients

that were kept: __________

Does the clinic have access to an on-site pharmacy? □ yes □ no

Does the clinic have 340b status? □ yes □ no




%

Percentage of HIV patients that are on ART


Percentage of HIV patients that are virally suppressed


Percentage of HIV patients who have missed scheduled appointments in the passed 6 months




How many Full Time Equivalent (FTE)* providers (clinical or other provider types) did the clinic have in calendar year? ______

Type of provider

Number of FTE provider(s)

Physician^


Physician Assistant


Nurse Practitioner


Pharmacist


Registered Nurse, Licensed Nurse


Dietician


Case Manager


Social Worker


Substance Abuse Counselor


Laboratory staff


Other

type:


*FTE is the ratio of the total number of paid hours during a period divided by the number of working hours in that period. An FTE of 1.0 means that the person is equivalent to a full-time worker, while an FTE of 0.5 indicates that the worker is only half-time

^Physicians in residency training should not be included


Average number of patients seen, per day, by 1 FTE staff in calendar year:

Physician(s) ________

Physician Assistant(s) ________

Nurse Practitioner(s) ________

Pharmacist(s) ________

Registered Nurse(s), Licensed Nurse(s) ________

Case Manager(s) ________

Social Worker(s) ________

Substance Abuse Counselor(s) ________

Other(s)

type: ________



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