0920-0573 NHSS - Standards Evaluation Report (SER) Form 29AUG2025

National HIV Surveillance System (NHSS)

Attachment 3(d)
Standards Evaluation Report Form

Form Approved OMB No. 0920-0573
Exp. Date: 2/28/2026

Standards Evaluation Report (SER)
Surveillance Program Performance
Jurisdiction’s name: ______________________
Provide the following:

Name

1. Primary Surveillance Contact:
2. Secondary Surveillance Contact:
3. S&C Overall Responsible Party:

email

A. Death Ascertainment
☐ We are a separately funded city AND all death ascertainment is done at the state level. (Skip to section
B: Laboratory).
☐ We are a state, territory, or separately funded city and perform our own death ascertainment. (Respond
to the questions below and complete the table).
Vital records
1. Frequency of linkages done
in and entered in
eHARS:
2. Linked with deaths occurring
through:
3. Linkages included dates of
death for ALL cases and entered
in eHARS?
4. Linkages included causes of
death for ALL cases and
imported in eHARS?
5. Searched all vital records
deaths mentioning HIV and
entered previously unreported
cases in eHARS?

Standard
Annual
will increase to semiannual on
2026 SER and quarterly on
2028 SER

Result

December

MM/YYYY

Yes
Yes

Yes

For unmet vital records standards provide an explanation for why each standard was not met and plans for
meeting it in the future. (will only appear if there are unmet standards)
6. Are you prohibited from searching the National Death Index (NDI) by state, local, or territorial law?
☐ Yes ☐ No

Public reporting burden of this collection of information is estimated to average 8 hours 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 Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30329; ATTN: PRA (0920-0573).

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If No to Q6:
NDI Early-release version
7. Linked with deaths occurring through:
NDI Final version
8. Linked with deaths occurring through:
Social Security Death Master File (SSDMF)
9. Last year linked with SSDMF

Standard

Result

December

MM/YYYY

December

MM/YYYY

At least once during
- *

10. If linked in , linked with deaths
MM/YYYY
December
occurring through:
*If unable to link with NDI during , then a linkage to SSDMF is required in . If able to
link with NDI, then refer to the Standard indicated in the table.
If Yes to Q6
NDI
11. Last year you consulted with legal counsel to
reassess determination to prohibit linking to the
NDI:
12. If legal counsel was consulted in ,
upload documentation of assessment
Social Security Death Master File (SSMDF)
13. Linked with deaths occurring through:

Standard

Result

At least once during
-
documentation
December

MM/YYYY

For unmet NDI standards provide an explanation for why the standard was not met and plans for meeting
it in the future (will only appear if there are unmet standards)
For unmet SSDMF standards provide an explanation for why the standard was not met and plans for
meeting it in the future (will only appear if there are unmet standards)
B. Laboratory
1. In , did your program review and update the list of

laboratories that perform HIV-related laboratory tests that should be
reported to your program?

2. In , did your program review and update, as necessary, all
laboratory reporting/processing/importing tools (e.g., SAS code)?
3. Last year a laboratory assessment of all laboratories that report to the
health department was conducted including maintenance of documentation
on the types of tests performed by each laboratory identified in the
laboratory assessment including use of ambiguous LOINCs (Logical
Observation Identifiers Names and Codes) by different labs:
4. Frequency that the CDC-supplied SAS program (or equivalent program)
was run to monitor lab data quality and volume entered in eHARS for each
laboratory and test type and respond as needed:

Standard

Result

Yes
Yes
At least
once during

Monthly

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For unmet laboratory process standards provide an explanation for why the standard was not met and
plans for meeting it in the future. (there will be a separate text box for each unmet standard that will only
appear if the standard was not met)
5. Are you aware of any lapses in laboratory reporting of HIV-related test results for persons who reside
within your jurisdiction that resulted in missing laboratory data in your December data transfer
to CDC?
☐ Yes
Year of
Approximately what percentage of your Approximately what percentage of your total
specimen
total jurisdiction’s laboratory volume is jurisdiction’s CD4 results (< 200 and ≥ 200) and
collection
missing for the calendar year indicated? viral load results (detectable and undetectable) are
missing for the calendar year indicated?
*

*At a minimum, lab results through September 2023
☐ No
6. Describe how your program has expanded or plans to expand electronic data exchange capacity for
laboratory data as well as other sources of data (e.g. electronic medical records).
C. Pediatric/Perinatal
1A. In , did you link case reports for persons with diagnosed HIV
infection whose sex is not male to the birth certificate data file from the vital
records office for all births to identify all perinatally exposed
infants with a residence of birth in your jurisdiction?
☐ Yes
☐ No

Birth Ascertainment

1B. If no to 1A, please describe why you did not link with the birth
certificate data file.
[Free text]
1C. If yes to 1A, did you enter all the information identified from the linkage
to the birth certificate data file in eHARS before your final December
data transfer to CDC?
☐ Yes
☐ No
1D. If no to 1C, please describe why you did not enter in eHARS all the
information identified from the link to the birth certificate data file.
[Free text]

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2A. Provide the number of perinatally HIV exposed infants born in that were identified through the match to birth certificates. *This should
include exposed infants previously known to the HIV surveillance program.

Number of perinatally
HIV exposed infants
for birth year

2B. Does this match with the number of perinatally exposed infants reported
to CDC through your final December data transfer?
☐ Yes
☐ No
2C. If this does not match, please describe the reasons the numbers do not
match (e.g., X perinatally exposed infants reported to health department that
were not in the state/local birth certificate data because the infant was a
resident of another jurisdiction).

Perinatal HIV
Exposure Reporting*

3. Provide percentage of perinatally HIV-exposed infants born in

who have HIV infection status determined by 18 months of
age (Standard: 85%):

*Required for California, Chicago, District of Columbia, Florida, Georgia, Houston, Los Angeles, Louisiana, Maryland,
Mississippi, New Jersey, New York City, North Carolina, Ohio, Philadelphia, Tennessee, and Texas. All others are encouraged to
respond but are not required.

D. Geocoding and Data Linkage
1. In , how frequently did your program geocode addresses in eHARS
to the census tract level and ensure the census tract is populated in eHARS?
2. In , did your program submit linked American Community Survey
(ACS) data within 30 days of the availability of the ACS data? (will only appear
if the jurisdiction does not send census tracts to CDC)

Standard

Result

Quarterly
Yes

For all unmet geocoding and data linkage standards provide an explanation why the standard was not met
and plans for meeting it in the future. (will only appear if there are unmet standards)
E. Cluster Detection
1. In , how frequently did your program analyze molecular data by
using CDC-recommended approaches to identify HIV clusters and outbreaks?
2. In , how frequently did your program conduct time-space analysis
by using CDC-recommended approaches to identify HIV clusters and outbreaks?

Standard

Result

Monthly
Monthly

For unmet cluster detection standards provide an explanation why the standard was not met and plans for
meeting it in the future. (will only appear if there are unmet standards)
F. Monthly eHARS Data Transfer to CDC

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1. At minimum, conduct an end-of-month transfer of the eHARS data
file to CDC by the established deadline (no later than 10am ET 3
business days before the end of each calendar month).

Standard
12 on-time
monthly
submissions

Result
Populated by
CDC

If the standard was not met, provide an explanation why the standard was not met and plans for meeting it
in the future. (will only appear if there are unmet standards)
G. HIV Surveillance Policies and Procedures
1. Last year the HIV surveillance program policies and procedures were
reviewed and update document and train as needed.

Standard

Result

If the standard was not met, provide an explanation why the standard was not met and plans for meeting it
in the future. (will only appear if there are unmet standards)
H. Data Quality Outcome Standard
Standard
1. Of all persons with HIV infection diagnosed during , at least (≥) 97% have
been reported to CDC (i.e., pass all standard data edit checks), assessed December
Upload the SAS output: [upload field]

Result

If the standard was not met, provide an explanation why the standard was not met and plans for meeting it
in the future. (will only appear if there are unmet standards)
I. Outcome Standards Calculated at CDC
NOTE: Below your program’s results have been pre-populated for the outcome standards based on your
December data transmission to CDC.
Completeness and Timeliness of Case Ascertainment
Standard
Of the expected number of persons whose HIV infection was diagnosed during ,
at least (≥) 95% are reported in eHARS, assessed December
Of the expected number of persons whose HIV infection was diagnosed during ,
at least (≥) 90% are reported in eHARS within (≤) 90 days of the diagnosis, assessed
December
Of all persons with diagnosed HIV infection whose diagnoses were first entered in
eHARS during , at least (≥) 75% were first entered within (≤) 60 days after the
date of diagnosis.
This measure will change starting on the 2027 SER to: Of all persons with diagnosed HIV
infection whose diagnoses were first entered in eHARS during , at least (≥) 75%
were first entered with (≤) 30 days after the date of diagnosis.

Result

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Duplicate Review
Standard
Of all persons with diagnosed HIV infection who were entered in eHARS through the end
of (cumulative), less than or equal to (≤) 1% have duplicate case reports,
assessed December
Of all pairs on the Routine Interstate Duplicate Review (RIDR) list received January
, at least (≥) 98% were resolved by June 30,
Of all pairs on the Routine Interstate Duplicate Review (RIDR) list received July , at least (≥) 98% were resolved by December 31,
Of all pairs on the Cumulative Interstate Duplicate Review (CIDR) list received January
, at least (≥) 98% were resolved by December 31,

Completeness of Laboratory Reporting
Standard
Of all CD4 laboratory test results with a specimen collected during , the total
volume of (deduplicated) CD4 test results was at least (≥) 95% of the median annual
volume of (deduplicated) CD4 test results from the previous 3 years, assessed December
.
Of all viral load laboratory test results with a specimen collected during , the
total volume of (deduplicated) viral load test results was at least (≥) 95% of the median
annual volume of (deduplicated) viral load test results from the previous 3 years, assessed
December .
Of all persons with HIV infection diagnosed during , at least (≥) 60% have an
analyzable nucleotide sequence, assessed December
Timeliness of Laboratory Reporting
Standard
Of all CD4 and viral load results entered in eHARS during , at least (≥) 90% are
entered within (≤) 30 days after the specimen collection date.
Of all diagnostic results entered in eHARS during , at least (≥) 90% were
entered within (≤) 60 days after the date of specimen collection.
This measure will change starting on the 2027 SER to: Of all diagnostic results entered in
eHARS during , at least (≥) 90% were entered within (≤) 30 days after the date
of specimen collection.
Of all sequences entered in eHARS during , at least (≥) 85% were entered
within (≤) 60 days after the date of specimen collection.
Validity of Laboratory Results
Standard
Of all laboratory test results entered in eHARS during , at least (≥) 97% have a
valid test result and a known specimen collection date (month and year), assessed
December .
Death Ascertainment
Standard

Result

First
assessed
on the
2026 SER
Result

Result

Result

Result

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Of all deaths that occurred during , at least (≥) 85% have an underlying cause of
death, assessed December
Of all deaths entered in eHARS during with vital statistics as one of the
document sources, at least (≥) 90% of the deaths were entered within 4 calendar months
of the date of death, assessed December .
Risk Factor Ascertainment
Standard
Of all persons with diagnosed HIV infection who were first entered in eHARS during
, at least (≥) 80% have sufficient risk factor information to be classified into a
known transmission category, assessed December .
This measure will change starting on the 2028 SER to: Of all persons with diagnosed HIV
infection who were first entered in eHARS during , at least (≥) 85% have
sufficient risk factor information to be classified into a known transmission category,
assessed December .
Address Ascertainment
Standard
Of all persons entered in eHARS with HIV diagnosed in (regardless of
residence at diagnosis), at least (≥) 97% have a valid county FIPS code for the residence
at diagnosis, assessed December .

First
assessed
on the
2028 SER
Result

Result

Of all persons entered in eHARS who were living with diagnosed HIV infection at the
end of (regardless of jurisdiction of residence), at least (≥) 97% have a valid
county FIPS code for the residence at the end of , assessed December .
Of persons living with diagnosed HIV infection in the jurisdiction at the end of ,
at least (≥) 95% have a current address with a date that is in or later.
Completeness of Previous Negative HIV Test
Standard
Of all persons with HIV infection diagnosed during , at least (≥) 70% have a
known value for previous negative HIV test result (self-reports or documented), assessed
December .

Result

Of all persons with HIV infection diagnosed during who have a previous
negative test result (self-reported or documented), at least (≥) 50% have a valid date of
documented negative test result, assessed December .
Completeness of Geocoding
Standard
Of all persons with HIV infection diagnosed during (regardless of residence at
diagnosis), at least (≥) 90% have a census tract for their residence at diagnosis, assessed
December .
Upload the SAS output: [upload field] – will only appear for jurisdictions that do not send
CDC census tract data

Result

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Exp. Date: 2/28/2026

Of all persons entered in eHARS who were living with diagnosed HIV infection at the
end of (regardless of jurisdiction of residence), at least (≥) 90% have a census
tract for the residence at the end of evaluation year, assessed December .
Upload the SAS output: [upload field] – will only appear for jurisdictions that do not send
CDC census tract data
Completeness of Antiretroviral Use History
Standard
Of all persons with HIV infection diagnosed during , at least (≥) 70% have
antiretroviral use history, assessed December .

Result

For all unmet outcome standards provide an explanation why the standard was not met and plans for
meeting it in the future in the appropriate space below. (there will be a separate text box for each unmet
standard that will only appear if there are unmet standards)
J. Cluster Detection and Response Outcome Standards
Outcome Standard
1. Of all clusters that meet CDC’s cluster report form criteria detected
during the evaluation year, ≥90% had an initial cluster report form
submitted to CDC by the submission deadline
a. Number of initial cluster report forms submitted to CDC by the
submission deadline for clusters that first meet CDC’s cluster
report form criteria detected during
b. Number of priority molecular clusters that meet CDC’s cluster
report form criteria first detected during (include
those detected through both national and local analysis)
Upload the SAS output: [upload field]
c. Number of time-space clusters or other clusters of concern that
first meet CDC's cluster report form criteria during
2. Of clusters that meet CDC’s criteria for an annual or closeout
cluster report form, ≥90% had an annual or closeout cluster report
form submitted to CDC by the submission deadline
a. Number of annual or closeout cluster report forms submitted to
CDC by December

b. Number of clusters that meet CDC’s criteria for an annual or
closeout cluster report form during

Result
Calculated as
1a/(1b+1c)*100
Field
populated
by CDC
(CRF
REDCap)
Field
populated
by HD
Field
populated
by HD
Calculated as
2a/2b*100
Field
populated
by CDC
(CRF
REDCap)
Field
populated
by CDC
(CRF
REDCap)

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3. Of people with HIV in clusters for which a cluster report form was
submitted during the evaluation year, ≥90% had cluster variables
entered in eHARS
a. Number of people with HIV in clusters residing in the
jurisdiction reported on cluster report forms during
with cluster ID populated in eHARS
b. Number of people with HIV in clusters residing in the
jurisdiction based on the most recent cluster report form
submitted for each cluster during

Calculated as
3a/3b*100
Field
populated
by CDC
(eHARS)
Field
populated
by CDC
(CRF
REDCap)

For all unmet outcome standards provide an explanation why the standard was not met and plans for
meeting it in the future in the appropriate space below. (there will be a separate text box for each unmet
standard that will only appear if there are unmet standards)
K. Data Reporting and Dissemination
1. Last year that your program published and disseminated a comprehensive
revision of your integrated HIV Epidemiologic Profile:
2. If your program did not do a comprehensive revision of your integrated
Epidemiologic Profile in , did your program update the executive
summary and core epidemiologic data including tables and figures? The annual
update can be in the form of fact sheets, supplemental reports, slide sets, or other
standardized reports used by the state.
3. Did your program publish and disseminate an annual HIV surveillance report
in ?
4. Did your program share summary information about clusters and CDR
activities (for example, in an annual report or public dashboard) in ?
5. In , did your program’s reports incorporate analyses that describe
relevant syndemics?

Standard
At least
once during

Result

Yes

Yes
Yes
Yes

For all unmet data reporting and dissemination standards provide an explanation why the standard was
not met and plans for meeting it in the future. (will only appear if there are unmet standards)
For all met standards provide the URL for the report. (there will be a separate text box for each type of
report)
6. Describe how your program has increased availability and accessibility of data displays such as data
dashboards.

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L. Security and Confidentiality
In :
1. Did your program fully comply with the Data Security and Confidentiality
Guidelines for HIV, Viral Hepatitis, Sexually Transmitted Disease, and
Tuberculosis Programs: Standards to Facilitate Sharing and Use of Surveillance
Data for Public Health Action (2011); hereafter referred to as the NCHHSTP
guidelines?
2. Did your program ensure all persons with access to HIV data (including IT
personnel) complete an annual security and confidentiality training that is consistent
with the NCHHSTP guidelines, sign a confidentiality statement, and store it in the
personnel file?
3. Did your program conduct the required annual review of your security and
confidentiality policies and procedures to assess whether changes in legislation or
regulations, technology, priorities, personnel, or other situations require updates in
policies and procedures?
4. Did your program make enhancements or updates to security and confidentiality
policies and procedures, as needed? (If none were needed, select N/A)
5. Did your program apply the NCHHSTP guidelines to all sub-contractors and subrecipients funded through PS18-1802 that have access to or maintain confidential
HIV data?
6. Did your program implement secure procedures for data sharing, including Data to
Care (D2C) activities, within the context of existing laws, including within your
public health program and with external partners (such as sub-recipients)?
7. Did your program implement practices that support secure sharing and use of HIV
data across necessary programs within the health department for collaboration with
the Medical Monitoring Project (MMP) (if applicable)?
8. Did your program immediately investigate all data security breaches that did not
involve the release of personally identifiable information (PII)? (If there were no
breaches, select N/A) If N/A is selected, a and b will not appear.
a. Did your program report each non-PII breach to the ORP?
b. Did your program take steps to ensure immediate investigation of all breaches of
data security protocol, document investigation findings and identify and
implement corrective actions?
9. Did your program immediately investigate all breaches occur that resulted in the
release of PII to unauthorized persons? (If there were no breaches, select N/A) If
N/A is selected, a and b will not appear.
a. Did your program report each PII breach to the ORP, CDC, and (if warranted) to
law enforcement agencies?
b. Did your program implement corrective actions for each breach to avoid similar
incidents in the future?

Yes

No

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For all ‘No’ responses above, please describe why your program was non-compliant and what corrective
actions have been/will be implemented to ensure it will not occur in the future. (will only appear if No is
selected for any of the S&C questions)

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N/A

☐