Form 1 Data Elements

Form approved

OMB No. 0920-XXXX

Expiration date:

Attachment 3

Changes in the information content of nationally notifiable STD case report by data element

Sexually Transmitted Disease (STD) Morbidity Surveillance System

Updated July 23, 2009

Changes in the information content of

nationally notifiable STD case report by data element

Public reporting burden of this collection of information is estimated to average 20 minutes 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 persons 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 Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; Attn: PRA (0920-XXXX)

Data Element Name	Data Element Definition	Data Element "legal" Values	Variable Status*	Recommended/Optional By STD**
Treatment date	Date treatment initiated for the condition that is the subject of this case report.	YYYYMMDD format (Unknown=99999999)	New	Rec S Opt CT, G, CH
HIV status?	Documented or self-reported HIV status at this time.	P = HIV positive	New	Rec S Opt CT, G, CH
		N = HIV negative
		E = Equivocal HIV test result
		U = Unknown
		R = Refused to answer
		D = Did not ask
Had sex with an anonymous partner within past 12 months?		Y = Yes	New	Rec S Opt CT, G, CH
		N = No
		R = Refused to answer
		D = Did not ask
Had sex with a person known to him/her to be an IDU within past 12 months?		Y = Yes	New	Rec S Opt CT, G, CH
		N = No
		R = Refused to answer
		D = Did not ask
Had sex while intoxicated and/or high on drugs within past 12 months?		Y = Yes	New	Rec S Opt CT, G, CH
		N = No
		R = Refused to answer
		D = Did not ask
Exchanged drugs/money for sex within past 12 months?		Y = Yes	New	Rec S Opt CT, G, CH
		N = No
		R = Refused to answer
		D = Did not ask
Had sex with a person who is known to her to be an MSM within past 12 months?	NOTE: For women only.	Y = Yes	New	Rec S Opt CT, G, CH
		N = No
		R = Refused to answer
		D = Did not ask
Engaged in injection drug use within past 12 months?		Y = Yes	New	Rec S Opt CT, G, CH
		N = No
		R = Refused to answer
		D = Did not ask
During the past 12 months, which of the following injection or non-injection drugs have been used?		Crack	New	Rec S Opt CT, G, CH
		Cocaine
		Heroin
		Methamphetamines
		Nitrates/Poppers
		Erectile dysfunction (ED) medications (e.g., Viagra)
		Other drug(s) used?
		No drug use reported
Been incarcerated within past 12 months?		Y = Yes	New	Rec S Opt CT, G, CH
		N = No
		R = Refused to answer
		D = Did not ask
History of ever having an STD prior to this STD diagnosis?	Does the patient have a history of ever having had an STD prior to the condition reported in this case report?	Y=Yes, patient has a history of STD	New	Rec S Opt CT, G, CH
		N=No, patient has never had a prior STD
		U=Unknown if patient has had a prior STD
		R = Patient refused to answer any questions regarding prior STD history
Have you met sex partners through the Internet in the last 12 months?	Did the patient use an online computer site to exchange messages by typing them onscreen to engage in conversation with other visitors to the site for the purpose of having sex?	Y = Yes	New	Rec S Opt CT, G, CH
		N = No
		R = Refused to answer
		D = Did not ask
Total number of sex partners last 12 months?	Total number of sex partners that the case patient has had in the last 12 months. Total partners equals the sum of all male, female, and transgender partners during the period.	###	New	Rec S Opt CT, G, CH
		888=Patient refused to answer questions regarding number of sex partners
		999=Unknown number of sex partners in last 12 months
Clinician-observed lesion(s) indicative of syphilis were identified at which of the following anatomic site(s)? (Mark all that apply.)	If condition = any stage of syphilis, report anatomic site(s) of clinician-observed lesion(s) (e.g., chancre, rash, condyloma lata) at time of initial exam or specimen collection. Mark all that apply.	A=Anus/Rectum	New	Rec S Opt CH
		B=Penis
		C=Scrotum
		D=Vagina
		E=Cervix
		F=Nasopharynx
		G=Mouth/Oral cavity
		H=Eye/conjunctiva
		I=Head
		J=Torso
		K=Extremities (Arms, legs, feet, hands)
		N= No lesion noted
		O=Other anatomic site not represented in other defined anatomic sites
		U=Unknown
Type of non-treponemal serologic test for syphilis	What type of non-treponemal serologic test for syphilis was performed on specimen collected to support case patient's diagnosis of syphilis?	1= Rapid Plasma Reagin (RPR)	New	Rec S
		2= Venereal Disease Research Laboratory test (VDRL) (serology)
		3=VDRL test of cerebrospinal fluid (CSF)
		9 = Unknown test type
Quantitative syphilis test result	If the test performed provides a quantifiable result, provide quantitative result (e.g. if RPR is positive, provide titer, e.g. 1:64)	####	New	Rec S
Census tract of case-patient residence	Census tract where the address is located is a unique identifier associated with a small statistical subdivision of a county. Census tract data allows a user to find population and housing statistics about a specific part of an urban area. A single community may be composed of several census tracts.	6-character length alphanumeric	New	Opt CT, G, CH, S
STD IMPORT	Was case imported? Was disease acquired elsewhere? Indicates probable location of disease acquisition relative to reporting state.	N - Not an imported case	Revised, adopted National Notifiable Disease Surveillance System (NNDSS) standard format for variable responses.	Opt CT, G, CH, S
		C - Yes imported from another country
		S - Yes, imported from another state
		J - Yes, imported from another county/jurisdiction in the state
		D - Yes, imported but not able to determine source state and/or country
		U - Unknown
Date of initial health exam associated with case report "health event"	Date of earliest healthcare encounter/visit /exam associated with this event/case report. May equate with date of exam or date of diagnosis.	YYYYMMDD format (Unknown=99999999)	Revised; added date type as specific date’.	Opt CT, G, CH, S
Date of first report of case/event to public health system	Date of first report of case to local or state health department (first tier of public health system in reporting jurisdiction; may equate to city, county, region, or state public health system level).	YYYYMMDD format (Unknown=99999999)	Revised; added date type as specific date’.	Opt CT, G, CH, S
Date case report initially sent from reporting jurisdiction to CDC	INITIAL date case report was sent from reporting jurisdiction to CDC. Generated by the reporting jurisdiction at the time of report to CDC. Can be generated by the information system.	YYYYMMDD format (Unknown=99999999)	Revised; added date type as specific date’.	Opt CT, G, CH, S
Had sex with a male within past 12 months?		Y = Yes	Revised; modified question response format.	Rec S Opt CT, G, CH
		N = No
		R = Refused to answer
		D = Did not ask
Had sex with a female within past 12 months?		Y = Yes	Revised; modified question response format.	Rec S Opt CT, G, CH
		N = No
		R = Refused to answer
		D = Did not ask
INFOSRCE - Facility Type (STD dx, rx)	Setting or health care facility where a person first received diagnosis, treatment or testing for STD or associated syndrome reported in this case report (i.e., facility type of STD diagnosis, facility type where person was tested for STD).	01=HIV Counseling and Testing Site	Revised; updated question response categories.	Rec CT, G, CH, S
		02=STD clinic
		03=Drug Treatment
		04=Family Planning
		06=Tuberculosis clinic
		07=Other Health Department Clinic
		08=Private Physician/HMO
		10= Hospital - Emergency Room; Urgent Care facility
		11=Correctional facility
		12=Laboratory
		13=Blood Bank
		14=Labor and delivery
		15=Prenatal
		16=National Job Training Program
		17=School-based Clinic
		18=Mental Health Provider
		29=Hospital - Other
		66=Indian Health Service
		77=Military
		88=Other
		99=Unknown (if data not available)
Method of Case Detection	How did the case patient first come to the attention of the health department for this condition?	20=Screening	Revised; updated question response categories.	Rec S Opt CT, G, CH
		21=Self-referred
		22=Patient Referred Partner
		23=Health Department referred partner
		24=Cluster related
		88=Other
Specimen source	Anatomic site or specimen type from which positive lab specimen was collected.	01=Cervix/Endocervix	Revised; updated question response categories.	Rec CT, G Opt S, CH
		02=Lesion-Genital
		03=Lesion-Extra Genital
		04=Lymph Node Aspirate
		05=Oropharynx
		06=Ophthalmia/Conjunctiva
		07=Other
		08=Other Aspirate
		09=Rectum
		10=Urethra
		11=Urine
		12=Vagina
		13=Blood/Serum
		14 - Cerebrospinal fluid (CSF)
		88=Not Applicable
		99=Unknown
American Indian/ Alaska native?	Case patient reported Am Indian/Alaska Native (AI/AN) race	Y = Yes; Variable value is Y or Blank, dependent upon case-patient's reported race.	Revised, per 1997 OMB Directive 15 and based on U.S. Census population data.	Rec CT, G, CH, S
Asian?	Case patient reported Asian race	Y = Yes; Variable value is Y or Blank, dependent upon case-patient's reported race.		Rec CT, G, CH, S
Black/African American?	Case patient reported black/African american (B) race	Y = Yes; Variable value is Y or Blank, dependent upon case-patient's reported race.		Rec CT, G, CH, S
Native Hawaiian/ Pacific Islander?	Case patient reported Native Hawaiian/Pacific Island (NH/PI) race	Y = Yes; Variable value is Y or Blank, dependent upon case-patient's reported race.		Rec CT, G, CH, S
White?	Case patient reported White (W) race	Y = Yes; Variable value is Y or Blank, dependent upon case-patient's reported race.		Rec CT, G, CH, S
Other race?	Case patient reported some other race (not AI/NA, Asian, Black, NH/PI, white)	Y = Yes; Variable value is Y or Blank, dependent upon case-patient's reported race.		Rec CT, G, CH, S
Refused to report race	Case patient refused to report race	Y = Yes; Variable value is Y or Blank, dependent upon case-patient's reported race.		Rec CT, G, CH, S
Unknown race	Case patient could not answer this question for any reason	Y = Yes; Variable value is Y or Blank, dependent upon case-patient's reported race.		Rec CT, G, CH, S
State	State reporting case information & jurisdiction of case (based on patient residence)	2-digit FIPS code	No change	Rec CT, G, CH, S
Year	MMWR Year for which case information was reported to CDC. Derived from MMWR week.	2-digit year	No change	Rec CT, G, CH, S
Case report ID	Unique case report ID assigned by state	Non-identifying ID; 6 digit numeric.	No change	Rec CT, G, CH, S
Week	MMWR week on surveillance calendar – assigned by reporting jurisdiction.	01 through 53 – representing week during surveillance year	No change	Rec CT, G, CH, S
Event or diagnosis	STD or associated syndrome (health event) for which the case-patient has been diagnosed	Chancroid, Chlamydia, Gonorrhea, Primary syphilis, Secondary syphilis, Early latent syphilis, Late latent syphilis, Unknown latent syphilis, Late syphilis with clinical manifestations	No change	Rec CT, G, CH, S
County	Standard FIPS code for county of case-patient’s residence in reporting state	3-digit county FIPS	No change	Rec CT, G, CH, S
Date of birth	Date of birth of case-patient	YYYYMMDD	No change	Opt CT, G, CH, S
Age	Age of case-patient at time of initial exam or specimen collection for the case report “condition”	###	No change	Rec CT, G, CH, S
Age type	Indicates the units (years, months, etc.) for AGE field	0=0-120 years; 1=0-11 Months; 2=0-52 weeks; 3=0-28 days; 9= Age unknown	No change	Rec CT, G, CH, S
Sex	Current sex of patient	1= Male; 2 = Female; 9 = Unknown	No change	Rec CT, G, CH, S
Outbreak	Indicates whether the case was associated with an outbreak	1=Yes; 2=No; 9 = Unknown	No change	Rec CT, G, CH, S
ZIP	5-digit Zip code of residence of the case patient.	#####; (Unknown=99999, if data not available)	No change	Rec CT, G, CH, S
Pregnant - initial exam	Was the case patient pregnant at time of initial exam for the condition reported in this case report?	1=Yes	No change	Rec S Opt CT, G, CH
		2=No
		9=Unknown
Neurological involvement?	If event = some stage of syphilis, does the patient have neurologic involvement based on current case definition?	1=Yes, Confirmed	No change	Rec S
		2=Yes, Probable
		3=No
		9=Unknown
Hispanic/Latino?	Indicator for case-patient's Hispanic/Latino ethnicity.	Y=Yes	No change	Rec CT, G, CH, S
		N=No
		U=Unknown
		R = Refused to answer
Date of laboratory specimen collection	Date of collection of initial laboratory specimen used for diagnosis of health event reported in this case report.	YYYYMMDD format (Unknown=99999999)	No change	Rec CT, G, CH, S

*Variable Status:

New = Data variable added, NOT currently OMB-approved (n = 17)

Revised = Currently OMB-approved variable values are revised (n = 10)

No change = Variable is currently OMB-approved per Weekly and Annual Morbidity and Mortality Reports (MMWR, OMB #0920-0007) (n = 16)

**Recommended/Optional by STD

Rec = Recommended

Opt = Optional

STDs: CH = Chancroid, CT = Chlamydia, G = Gonorrhea, S = Syphilis

Page 8 of 8