Form 41 Project Overview

OMB No.: 0915-0285. Expiration Date: XX/XX/20XX

DEPARTMENT OF HEALTH AND HUMAN SERVICES Health Resources and Services Administration Project Overview Form		FOR HRSA USE ONLY
		Grant Number	Application Tracking Number
HIV Testing, PrEP Prescriptions, and Linkage to Care Estimates
Provide estimates for each service as a result of PCHP-supported activities in calendar year 2020 (1/1/2020 through 12/31/2020). A response is required for each field. Your 2018 Uniform Data System (UDS) report data may help you establish 2020 estimates for the PCHP metrics. Click on the “i” information button next to the objective for resources describing the related PCHP metric. Estimates will NOT affect your Health Center Program operational grant (H80) patient target or your performance measure targets set through your last Service Area Competition application. Refer to Appendix B of the PCHP instructions for detailed guidance on completing this form.
PCHP Objective	PCHP Metric		2020 Estimate
Increase the number of patients tested for HIV	Number of health center visits during which an HIV test was performed
Increase the number of patients tested for HIV	Number of patients tested for HIV
Increase the number of patients tested for HIV	Percentage of patients with a documented HIV test performed between the ages of 15 and 65 years
For those who test negative for HIV, provide HIV prevention education, and prescribe and support the use of clinically indicated PrEP	Number of patients who will receive a clinically-indicated PrEP prescription
For those who test positive for HIV, link to treatment	Percentage of patients newly diagnosed with HIV who were seen for follow-up treatment within 30 days of diagnosis

Health Center Program Scope of Project
Review your current approved Form 5A: Services Provided. Will a Scope Adjustment or Change in Scope request be necessary to ensure that all planned changes are on your Form 5A?	Select One Option
Yes, I reviewed my Form 5A and determined that my health center’s proposed activities will require a Scope Adjustment or Change in Scope request to modify Form 5A.	□
No, I reviewed my Form 5A and determined that my health center’s proposed activities will not require a Scope Adjustment or Change in Scope request to modify Form 5A.	□
Describe proposed changes to your Form 5A: Services Provided, Form 5B: Service Sites, and Form 5C: Other Activities/Locations, and provide a timeline for requesting the necessary modifications below. (Up to 1,000 characters counting spaces)

Technical Assistance
Technical assistance on the following topics would support the successful implementation of my PCHP project.	Select All That Apply
Using electronic health record data and health information technology enhancements to facilitate HIV prevention and clinical decision support	□
Building and sustaining community-based partnerships to support referrals for HIV prevention, and HIV treatment	□
Performing HIV prevention outreach to new patients and in-reach to existing patients	□
Supporting the use of PrEP, including prescribing, the use of prescription assistance programs, and PrEP navigators	□
Developing HIV testing and linkage to care policies and procedures	□
Evidence-based risk reduction strategies to decrease the likelihood of HIV infection and transmission	□
Treatment and harm reduction strategies for individuals with substance use disorders to decrease the likelihood of HIV infection and transmission	□
Telehealth in HIV prevention and HIV treatment, including tele-PrEP	□
Addressing HIV prevention and treatment access barriers, such as trauma, stigma, housing, substance use disorders, mental health conditions, privacy, and health center personnel cultural competencies	□
Successful strategies to sustain integrated primary care and HIV programs	□
Other (please describe in a comment)	□
My health center could provide peer support to others (please describe in a comment)	□

Comment: As desired, describe needs specific to the selected topic area(s) or define other topic areas. (Up to 1,000 characters counting spaces)

Public Burden Statement: Health centers (section 330 grant funded and Federally Qualified Health Center look-alikes) deliver comprehensive, high quality, cost-effective primary health care to patients regardless of their ability to pay. The Health Center Program application forms provide essential information to HRSA staff and objective review committee panels for application evaluation; funding recommendation and approval; designation; and monitoring. The OMB control number for this information collection is 0915-0285 and it is valid until XX/XX/XXXX. This information collection is mandatory under the Health Center Program authorized by section 330 of the Public Health Service (PHS) Act (42 U.S.C. 254b). Public reporting burden for this collection of information is estimated to average 1 hour per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14N136B, Rockville, Maryland, 20857 or paperwork@hrsa.gov.