HCV Elimination Plan Check-in
Please complete this form to provide an update on your HCV elimination activities, progress, and needs.
Participant/Program Name
*
Date of Check-in
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Role or Position
*
Please Select
Program Manager
Healthcare Provider
Community Worker
Public Health Official
Other
Current Status of HCV Elimination Activities
*
On Track
Delayed
Completed
Not Started
Screening and Treatment Data
*
Rows
Number Screened
Number Diagnosed
Number Treated
Number Cured
Since Last Check-in
Cumulative Total
Main Barriers or Challenges Encountered
Limited Funding
Lack of Awareness
Stigma/Discrimination
Limited Access to Testing
Limited Access to Treatment
Other
How would you rate your progress towards HCV elimination goals?
*
Not at all
1
2
3
4
Fully achieved
5
1 is Not at all, 5 is Fully achieved
Resources or Support Needed
Training/Education
Funding
Testing Supplies
Treatment Access
Community Outreach Materials
Other
Additional Comments or Feedback
Signature
*
Submit Check-in
Submit Check-in
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