attachment 13-historical data table.pdf

PS11-1113

Human Immunodeficiency Virus (HIV) Prevention Projects for YMSM of color and YTG persons of color

Attachment XIII: Historical Data Table

AGENCY CONTACT INFORMATION:

DUNS Number:

EIN Number:

Agency Name:

Mailing Address:

City:

State/Province:

Zip Code:

Agency Website:

Executive Director:

E-mail:

Phone:

Fax:

Board President/Chair:

E-mail:

Phone:

Fax:

Is your agency a Faith-based Organization?

NOTE: A faith-based agency is a non-government agency owned by religiously affiliated entities such as (1) individual churches, synagogues, temples, or other places of worship; or (2) a network or coalition of churches, mosques, synagogues, temples, or other places of worship.

Yes

No

Category Applying Under:

(Select the category for which you intend to apply. (Applicants may apply for Category A and/or B).

Category A:

HIV prevention services for high risk Young

Men of color Who Have Sex with Men (YMSM of color) and their partners regardless of age, gender, or race/ethnicity.

Category B:

HIV prevention services for high risk Young

Transgender (YTG) persons of color and their partners regardless of age, gender, or race/ethnicity.

Target Population: Must have provided HIV prevention or care services to the target population in accordance with the specific requirements for Category A and/or B:

for the past 24 months).

American Indian/Alaskan Native:

Asian:

Black/African American:

Native Hawaiian/Pacific Islander:

Legacy Asian/Pacific Islander:

Multi-race:

Unknown:

Other (specify) :

TOTAL Percentage of clients served:

Heterosexual:

MSM:

Intravenous Drug Use (IDU):

IDU/MSM:

IDU/ Heterosexual:

Non-IDU Drug Use:

TOTAL Percentage of clients served:

Type of Data: The data and information used to report the

Organization’s previous/past experience is based on: (Select

ONE)

Combined data from All programs in the organization (Overall)

Data from a single program within the organization (Single Program)

Program Name:

Service Type (e.g., GLI, CTR):

PS11-1113 Attachment XI: Historical Data Table REVISED 1-19-11

PURPOSE: The purpose of this worksheet is for the applicant to provide client-level data to support their HIV prevention experience serving the target population over the past 24 months.

Target Population:

What is the Primary Target Population that your agency has served for the past 24 months? Please list by ethnicity, race, targeted risk behavior, gender, age, and HIV status.

Description of Primary Target Population:

Examples: White, IDU, Men, 18-29, who are HIV+ or Non-Hispanic, Black, Heterosexual, Women,30-34 who are HIV-

Ethnicity (Select only one)

Race (Select only one)

Risk Behavior (Select only one)

Gender (Select only one)

Age Group (Select only one)

HIV Status (Select only one)

Hispanic/Latino

Non-Hispanic

American

Indian/Alaska n Native

Asian

Black/African

American

Native

Hawaiian/Pac ific Islander

Legacy

Asian/Pacific

Islander

White

Multi-race

Unknown

Other

(specify):

Heterosexual

Men who have sex with men

(MSM)

Intravenous

Drug Use

(IDU)

IDU/MSM

IDU/

Heterosexual

Non-IDU Drug

Use

Other (specify):

Male

Female

Transgender

M>F

F>M

13-17 years

18-29 years

30-34 years

35-44 years

45 + years

Negative

Positive

Unknown

Past Program Model(s): Select the program models (e.g., POL and CTR) that you have experience implementing.

Effective Behavioral Interventions (EBIs):

CLEAR

Community PROMISE

CONNECT

D-UP

Focus on Youth +ImPACT

Healthy Relationships

Many Men, Many Voices (3MV)

Modelo de Intervención

Psicomédica (MIP)

Mpowerment

Nia

Partnership for Health (PfH)

Popular Opinion Leader (POL)

Real AIDS Prevention Project

(RAPP)

RESPECT

Safety Counts

Self-Help in Eliminating Life-Threatening

Disease (SHIELD)

SiHLE

Sisters Informing Sisters on Topics about

AIDS (SISTA)

Sister to Sister

START

Street Smart

VOICES/VOCES

WILLOW

PS11-1113 Attachment XI: Historical Data Table REVISED 1-19-11

Health Education Risk Reduction (HERR) Activity:

Comprehensive Risk Counseling Services (CRCS)

Public Health Strategy (PHS):

Counseling, Testing and Referral Services (CTR)

If CTR, what type of testing do you provide:

Conventional (blood)

Rapid Testing

Not Applicable

If Rapid Testing, what brands do you use:

UniGold

OraQuick

OraSure

Clearview Stat Pack

Other:

Not Applicable

If your agency has prior experience implementing PHS, how long has your agency been implementing the PHS?

What is your organization’s HIV seropositivity rate for the past 24 months?

Ex: Example of Seropositivity Rate Calculation: 900 OraQuick rapid tests were conducted, and 11 tests were newly-identified clients testing positive, then the seropositivity rate would equal 1.2% (11/900 = 0.012 x 100 = 1.2%).

PS11-1113 Attachment XI: Historical Data Table REVISED 1-19-11

Instructions: Please provide the ACTUAL NUMBER of clients the agency has served for the past 24 months. Complete the data tables below illustrating the agency’s previous experience with the specific target population for that time period, broken out by ethnicity, race, risk behavior, gender, and age group and HIV status. Please list the top 6 target populations you have served.

*NOTE: Do NOT use PERCENTAGES when providing your client level data. Please only use whole numbers.

Within each row, check only one box within each column subheading to identify one complete target population (e.g., Non-Hispanic, Black/African American, IDU/Heterosexuals, Female, 35-44 years, HIV negative). In addition, in the final column of that row, you will type in the total number of clients within this population you served for the past 24 months. Please refer to the example below.

Example: 25 African American Females, with a risk of IDU/Heterosexuals, and of negative HIV serostatus between the ages of 35-44.

Ethnicity

(Select only one)

Race

(Select only one)

Risk Behavior

(Select only one)

Gender

(Select only one)

Age Group

(Select only one)

HIV Status

(Select only one)

Number of

Clients

(Do not use percentages)

Ex: Hispanic/Latino

Non-Hispanic

American

Indian/Alaskan Native

Asian

Black/African

American

Native

Hawaiian/Pacific

Islander

Legacy Asian/Pacific

Islander

White

Multi-race

Unknown

Other (specify):

Heterosexual

Men who have sex with men (MSM)

Intravenous Drug

Use (IDU)

IDU/MSM

IDU/

Heterosexual

Non-IDU Drug

Use

Other

(specify):

Male

Female

Transgender

30-34 years

35-44 years

45+ years

Negative

Positive

Unknown

PS11-1113 Attachment XI: Historical Data Table REVISED 1-19-11

Ethnicity

(Select only one)

Race

(Select only one)

Risk Behavior

(Select only one)

Gender

(Select only one)

Age Group

(Select only one)

HIV Status

(Select only one)

Number of

Clients

(Do not use percentages)

1. Hispanic/Latino

Non-Hispanic

American

Indian/Alaskan

Native

Asian

Black/African

American

Native

Hawaiian/Pacific

Islander

Legacy Asian/Pacific

Islander

White

Multi-race

Unknown

Other (specify):

Heterosexual

Men who have sex with men (MSM)

Intravenous Drug

Use (IDU)

IDU/MSM

IDU/ Heterosexual

Non-IDU Drug

Use

Other

(specify):

Male

Female

Transgender

30-34 years

35-44 years

45+ years

Negative

Positive

2. Hispanic/Latino

Non-Hispanic

American

Indian/Alaskan

Native

Asian

Black/African

American

Native

Hawaiian/Pacific

Islander

Legacy Asian/Pacific

Islander

White

Multi-race

Unknown

Other (specify):

Heterosexual

Men who have sex with men (MSM)

Intravenous Drug

Use (IDU)

IDU/MSM

IDU/ Heterosexual

Non-IDU Drug

Use

Other

(specify):

Male

Female

Transgender

18-24 years

25-34 years

35-44 years

45+ years

Negative

3. Hispanic/Latino

American

Indian/Alaskan

Native

Asian

Black/African

Heterosexual

Men who have sex with men (MSM)

Intravenous Drug

Use (IDU)

Male

Female

Transgender

M>F

F>M

13-17 years

18-29 years

30-34 years

35-44 years

45+ years

Negative

PS11-1113 Attachment XI: Historical Data Table REVISED 1-19-11

American

Native

Hawaiian/Pacific

Islander

Legacy Asian/Pacific

Islander

White

Multi-race

Unknown

Other (specify):

IDU/MSM

IDU/ Heterosexual

Non-IDU Drug

Use

Other

(specify):

4. Hispanic/Latino

American

Indian/Alaskan

Native

Asian

Black/African

American

Native

Hawaiian/Pacific

Islander

Legacy Asian/Pacific

Islander

White

Multi-race

Unknown

Other (specify):

Heterosexual

Men who have sex with men (MSM)

Intravenous Drug

Use (IDU)

IDU/MSM

IDU/ Heterosexual

Non-IDU Drug

Use

Other

(specify):

Male

Female

Transgender

30-34 years

35-44 years

45+ years

Negative

5. Hispanic/Latino

American

Indian/Alaskan

Native

Asian

Black/African

American

Native

Hawaiian/Pacific

Islander

Legacy Asian/Pacific

Islander

White

Multi-race

Unknown

Heterosexual

Men who have sex with men (MSM)

Intravenous Drug

Use (IDU)

IDU/MSM

IDU/ Heterosexual

Non-IDU Drug

Use

Other

(specify):

Male

Female

Transgender

30-34 years

35-44 years

45+ years

Negative

PS11-1113 Attachment XI: Historical Data Table REVISED 1-19-11

TOTAL NUMBER OF CLIENTS SERVED:

This number is the combined total number (all races, ethnicities, age groups and risk categories) of clients your agency served for HIV prevention services over the past 24 months:

Total Clients Served

Other (specify):

6. Hispanic/Latino

Non-Hispanic

American

Indian/Alaskan

Native

Asian

Black/African

American

Native

Hawaiian/Pacific

Islander

Legacy Asian/Pacific

Islander

White

Multi-race

Unknown

Other (specify):

Heterosexual

Men who have sex with men (MSM)

Intravenous Drug

Use (IDU)

IDU/MSM

IDU/ Heterosexual

Non-IDU Drug

Use

Other

(specify):

Male

Female

Transgender

13-17years

30-34 years

35-44 years

45+ years

Negative