HIV / STI Testing Tracker

CTR (900) FORM

HIV/STI Tracker Form
Attention!!!

09/22/2025

This form has been updated to align with the Virginia Department of Health’s new reporting standards for grant year 2025–2026. Please review each question carefully. While some questions may appear repetitive, they are necessary to ensure accurate and timely reporting. Thank you for your continued hard work and dedication.

Client Info

Clients name and D.O.B. will be stored in Jotform, it will not show up on CTR form.
Client's Name*

First NameLast Name
Date of Birth *

MonthDayYear
Year of Birth YYYY*
State*
Zip Code*
Client County or Independent City*

	Yes	Does not Apply
Individual who identify as males who were tested
Individuals who identify as Black/African American who were tested
Individuals who identify as Hispanic who were tested
Individuals that received an HIV test that will become aware of thier HIV status
Individuals with a negative HIV test who received a referral to disease prevention or other supportive services
Individuals referred to PrEP services who received a nonreactive HIV test result
Individuals linked to PrEP services who received a nonreactive HIV test result

	Yes	Does not Apply
# of individuals found to be positive screened for medical care and other supportive services
# of individuals found to be positive referred to medical care and other preventative services
# of individuals found to be positive linked to medical care and partner services
% found to be positive successfully linked to medical care in 90 days
% of individuals found to be positive given their test result
% of individuals linked to preventative services within 30 days
% of individuals found to be positive will be successfully linked to partner services within 30 days

	Positive	Negative	Test Not Preformed
Chlamydia Pharyngeal (Throat)
Chlamydia (Rectal)
Chlamydia (Urine) Amplification
Gonorrhoeae Pharyngeal (Throat)
Gonorrhoeae (Rectal)
Gonorrhoeae (Urine) Amplification
Syphilis
Hep B
HCV
HIV Confirmatory
HIV Rapid

	Yes	Does not Apply
# of clients provided rapid or Conventional testing for HCV
# of individuals who receive a preliminary positive HCV test will be linked to confirmatory testing within 30 days
# of individuals diagnosed with confirmed HCV will be linked to HCV-related medical care within 30 days.

	Yes	Does not Apply
# of indiviudals provided PrEP education
# of individuals who identify as male provided PrEP education
# of individuals who identify as Black/African American provided PrEP education
# of individuals who identify as Hispanic provided PrEP education
# of individuals who identify as high risk provided PrEP education
# of individuals screened for PrEP
# of individuals who identify as male screened for PrEP
# of individuals who identify as Black/African American screened for PrEP
# of individuals who identify as Hispanic screened for PrEP
# of individuals who identify as high risk screened for PrEP
# of individuals referred to PrEP
# of individuals who identify as male referred to PrEP
# of individuals who identify as Black/African American referred to PrEP
# of individuals who identify as Hispanic referred to PrEP
# of individuals who identify as high risk referred to PrEP
# of individuals linked to PrEP
# of individuals who identify as male linked to PrEP
# of individuals who identify as Black/African American linked to PrEP
# of individuals who identify as Hispanic linked to PrEP
# of individuals who identify as high risk linked to PrEP

CTR (900) FORM

	Screened	Need Identified	Referred or Provided
Health Benefits Enrollment
Risk-Reduction Intervention
Behavioral Health Services
Other Social Services

	Yes	Does not Apply
# of individuals screened for STI services and other supportive services
# of individuals screened for STI services and other supportive services who identify as male
# of individuals screened for STI services and other supportive services who identify as Black/African American
# of individuals screened for STI services and other supportive services who identify as Hispanic
# of individuals screened for STI services and other supportive services who identify as high risk
# of individuals referred to STI services and other supportive services
# of individuals referred to for STI services and other supportive services who identify as male
# of individuals referred to STI services and other supportive services who identify as Black/African American
# of individuals referred to STI services and other supportive services who identify as Hispanic
# of individuals referred to STI services and other supportive services who identify as high risk
# of individuals linked to STI services and other supportive services
# of individuals linked to STI services and other supportive services who identify as male
# of individuals linked to STI services and other supportive services who identify as Black/African American
# of individuals linked to STI services and other supportive services who identify as Hispanic
# of individuals linked to STI services and other supportive services who identify as high risk