• 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.

  • Date*
     - -

  • Client Info

    Clients name and D.O.B. will be stored in Jotform, it will not show up on CTR form.
  • Ethnicity *
  • Race (Check all that apply) *
  • Ethnicity STI*
  • Race (Check all that apply) STI*
  • Sex At Birth*
  • Sex At Birth STI*
  • Current Gender ID*
  • Current Gender ID STI*
  • Is client MSM*
  • Is client MSM STI*

  • Test Information

  • Previously Tested?*
  • HIV Test Result:*
  • Test Technology (click all that apply)*
  • Rapid Result*
  • Lab-Based Result*
  • Rows
  • Rows
  • Client tested for co-infections?*
  • If yes, Mark the co-infections for which the client was tested:*
  • Rows
  • Where was client referred?
  • Rows

  • RISK PROFILE AND SERVICE NEEDS

  • Client is at risk for HIV: STI*
  • Client is at risk for HIV:*
  • Is client eligible for PrEP referral? STI*
  • Is client eligible for PrEP referral??*
  • Was client referred to PrEP provider? STI*
  • Was client referred to PrEP provider?*
  • Why was client not referred for PrEP: STI*
  • Why was client not referred for PrEP:*
  • Was client provided PrEP Navigation? STI*
  • Was client provided PrEP Navigation?*
  • PrEP Awareness and Use: (check all that apply) STI*
  • PrEP Awareness and Use: (check all that apply)*
  • In the last 5 years, client has: (check all thet apply) STI*
  • In the last 5 years, client has: (check all thet apply)*
  • Rows
  • Rows
  • Rows
  •  
  • Should be Empty: