Pharmacy HIV PrEP Standing Order Quarterly Reporting Form

Please fill out the information below

Pharmacy name?

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If Other, please specify

Pharmacy address?

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If Other, please specify (Street, City, Zip)

Select reporting quarter

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Number of people < age 20 years

Number of people age 21-50 years.

Number of people age 51-65 years.

Number of people > 65 years.

Number of people identifying as Male

Number of people identifying as Female

Number of people identifying as Gender-Neutral

Number of people identifying as Intersex

Number of people identifying as Transgender

Number of people identifying as Other

Number as American Indian or Alaska Native

Number of people identifying as Asian

Number as Black or African American

Number as Native Hawaiian/Other Pacific Islander

Number of people identifying as White

Number of people identifying-Other

Number of people with Health Insurance Marketplace

Number of people with Commercial

Number of people with Medicaid

Number of people with Medicare

Number of people with Individual Commercial

Number of people with Self Pay

Number of people with Uninsured

Number of people with Other

Number who were referred for PrEP4IL program

No of people who were prescribed SO PrEP for 30

No of people who were prescribed SO PrEP for 90

Number referred to clinical provider?

Number who did not receive PrEP?

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