Question Response Options Details/Comments
General Information on IP
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Submitting Organization (Name of IP)
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Form Completed by (Name, Position, Email)
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Date of Submission
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Reporting period
Staffing and Human Resources
5. During the reporting period, did any PEPFAR-funded personnel within your project provide support to mpox?
☐Yes
☐No
- Which category of health care worker has provided support to mpox during the reporting period?
For each category, how many total staff across all project sites provided support to mpox? Cadre Total Number
☐Doctors ________________
☐Nurses ________________
☐CHW ________________
☐Data Clerks ________________
☐Other, specify_____________
Funding and Financial Support
7. Has any PEPFAR resources (funding, lab Resources, etc.) been used for mpox activities during the reporting period?
☐Yes
☐No
-
Amount of funding used
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Type of activities funded (e.g., mpox prevention, communication) during the reporting period.
Commodities and Supplies
10. Were any PEPFAR-procured commodities used for the mpox response during the reporting period?
☐Yes
☐ No
- List commodities used (e.g., PPE, testing kits, medications) ☐PPE
☐Testing kits
☐ Medications
☐ Other, specify_____________
HIV Services for Mpox Cases
12. Are mpox cases or suspected cases provided HIV testing as part of their care? ☐Yes
☐ No
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Number of suspected mpox cases tested for HIV during reporting period
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Number of suspected mpox cases who tested positive for HIV during the period.
15a. Number in PLHIV that had a clinical contact during the Reporting period
15b. Number of PLHIV screened or referred for mpox testing during the reporting period.
16. Number of mpox related deaths in PLHIV reported during the reporting period.
17. Please describe how documentation of HIV testing in suspected mpox cases is collected ☐ Integrated into HIV records
☐ Separate tracking
☐ Not tracked
☐ Other, specify________
Mpox Vaccine (Placeholder for when the vaccine becomes available)
19. Number of HIV at-risk clients who received a mpox vaccination during the reporting period.
20. Number of PLHIV who received a mpox vaccination during the reporting period.
