STD Clinic-based Surveillance

STD Surveillance Network (SSuN)

SSUN_Attachment 3A_STD Clinic Based Surveillance

STD Clinic-based Surveillance

OMB: 0920-0842

Document [doc]
Download: doc | pdf





SSuN Variable List

STD Clinic Based Surveillance

Data Elements



Attachment 3a



Contact Information:



Deborah Dowell, MD


National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention

DSTDP/ESB

Centers for Disease Control and Prevention

1600 Clifton Road NE, MS E02

Atlanta, GA 30333.


Phone: (404) 639-8334

Fax: (404) 639-8610

Email: [email protected]





07/21/2009

Form Approved

OMB No. 0920-09XX

Expiration Date XX/XX/20XX




STD Clinic Based Surveillance

Data Elements

Public reporting burden of this collection of information is estimated to average 2 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 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: OMB-PRA (0920-09XX)



Domain

Variable name

Type

Length

S=standardized

C=core

Question

Response coding

State

STATE

N

2

C

What state is the patient being reported by?

Standard reporting state FIPS code, 99 = default

Survey county

COUNTY

N

3

C

Which survey county submitted this patient's data?

FIPS code, example: 075 (County of SF), 999 = default

Survey city

CITY

N

4

C

Which survey city submitted this patient's data?

FIPS code, example: 3290 (City of SF), default = 9999

Survey facility

FACILITY

N

2

C

What survey facility submitted this patient's data?

10=Jefferson County (AL), 15=Druid (Balt), 16=Eastern (Balt), 20=Englewood (Chic), 21=Howard Brown (Chic), 22=Lakeview (Chic), 23=Roseland (Chic), 24=South Austin (Chic), 25=West Town (Chic), 30=Denver (CO), 40=Hartford (CT), 41=New Haven (CT), 50=Antelope Valley (Los Ang), 51= Central (Los Ang), 52=Curtis Tucker (Los Ang), 53=Hollywood-Wilshire (Los Ang), 54=Monrovia (Los Ang), 55=North Hollywood (Los Ang), 56=Pomona (Los Ang), 57=Ruth Temple (Los Ang), 58=Simms Mann (Los Ang), 59=South (Los Ang), 60=Torrance (Los Ang), 61=Whittier (Los Ang), 65=Delgado (Louisiana), 70=Bushwick (NYC), 71=Central Harlem (NYC), 72=Chelsea (NYC), 73=Corona (NYC), 74=East Harlem (NYC), 75=Fort Greene (NYC), 76=Jamaica (NYC), 77=Morrisania (NYC), 78=Richmond (NYC), 79=Riverside (NYC), 80=Health Clinic #1 (Philly), 81=Health Clinic #5 (Philly), 85=SF City Clinic (SF), 90=Richmond City (VA), 91=Henrico East (VA), 92=Chesterfield (VA), 93=Henrico West (VA) 95=Seattle-King County (WA)

Patient ID

PATIENTID

C

16

C

Unique patient identification number assigned by state

Locally defined

Visit date

VISDATE

Date

10

C

What date was the patient's current visit?

mm/dd/yyyy

Event ID

EVENTID

C

18

C

Event identification number assigned by state

Locally defined

Sex

SEX

N

1

C

Are you male, female, or transgender?

1 = Male, 2 = Female, 3 = Transgender unspecified, 4 = Transgender (M to F), 5 = Transgender (F to M), 9 = No answer/default

County of Residence

COUNTYRES

N

3

C

What county does the patient reside in?

FIPS code, example: 075 (County of SF), 999 = default/unknown

Age

AGE

N

2

C

How old are you?

Age in years, 99 = No answer/default

Hispanic

HISP

N

1

C

Are you of Hispanic ethnicity?

0 = No, 1 = Yes, 9 = No answer/default

Race

AIAN

N

1

C

Are you American Indian or Alaska Native?

0 = No, 1 = Yes, 9 = No answer/default

 

ASIAN

N

1

C

Are you Asian?

0 = No, 1 = Yes, 9 = No answer/default

 

PIH

N

1

C

Are you Pacific Islander or Hawaiian?

0 = No, 1 = Yes, 9 = No answer/default

 

BLACK

N

1

C

Are you Black?

0 = No, 1 = Yes, 9 = No answer/default

 

WHITE

N

1

C

Are you White?

0 = No, 1 = Yes, 9 = No answer/default

 

OTHERRACE

N

1

C

Are you another race not listed above?

0 = No, 1 = Yes, 9 = No answer/default

Sex of sex partners

MENSEX3

N

4

C

How many male sex partners have you had in the last 3 months?

#; 9999 = No answer, refused, default

 

FEMSEX3

N

4

C

How many female sex partners have you had in the last 3 months?

#; 9999 = No answer, refused, default

 

SEXOR3

N

1

C

Have you had sex with men, women, or both over the past 3 months?

1 = Men, 2 = Women, 3 = Both, 4 = None, 9 = No answer/default

 

NUMSEX3

N

4

C

How many sex partners have you had in the past 3 months?

#; 9999 = No answer, refused, default

 

SEXUALITY

N

1

C

Do you consider yourself gay (homosexual), straight (heterosexual), or bisexual?

1 = gay/homosexual, 2=straight/heterosexual, 3=bisexual, 9 = No answer/default

Pregnancy status

PREGNANT

N

1

C

Are you pregnant today?

0 = No, 1 = Yes, 8 = Don't know, 9 = No answer/default/male

HIV history

HIVRESULTLAST

N

1

C

What was your last HIV test result?

0 = Negative, 1 = Positive, 2 = Indeterminate, 9 = Unknown/didn't receive results/not applicable/default

Visit type

VISITTYPE

N

2

C

Type of current clinic visit

0 = HIV testing only, 1 = clinician, 2 = express/fast track, 3 = result only, 4 = treatment only, 5 = follow-up, 6 = DIS referral (not clinician visit), 7 = STI vaccine only, 8 = other, 9 = No answer/unknown

Patient symptoms

SYMPPT

N

1

C

Does the patient have any STD symptoms today?

0 = No, 1 = Yes, 9 = No answer, not asked, refused, default

GW history

GWEVER

N

5

S

Have you ever been diagnosed with GW?

0 = No, 1 = Yes, 9 = No/answer/default

HIV history

HIVEVERTEST

N

1

S

Have you ever been tested for HIV?

0 = No, 1 = Yes, 9 = No/answer/default

 

HIVDATE

C

7

S

When were you last tested for HIV?

mm/yyyy, put 99 in mm if pt doesn't know month, blank = unknown/default

 

HIVTESTTODAY

N

1

S

Was the patient tested for HIV at current visit?

0 = No, 1 = Yes, 9 = No/answer/default

 

HIVRESULTTODAY

N

1

S

What was the result of the HIV test at the current visit?

0 = Negative, 1 = Positive/preliminary positive, 2 = Indeterminant, 9 = Unknown

 

HIVTYPETODAY

N

1

S

What type of HIV test was used at current visit?

1 = Conventional, 2 = Rapid, 3 = Other

Vaccine History

HPVVAXHX

N

1

S

Have you ever been vaccinated for HPV/ human papillomavirus, cervical cancer?

0 = No/never, 1 = Yes partially, 2 = Fully, 8 = Unsure/don't know, 9 = No answer/default

 

HPVVAXADMIN

N

1

S

Was the patient given a dose of HPV vaccine at this visit?

0 = No, 1 = Quad dose #1, 2 = Quad dose #2, 3 = Quad dose #3, 4 = Quad dose #undefined, 5 = Bivalent dose #1, 6 = Bivalent dose #2, 7 = Bivalent dose #3, 8 = Bivalent dose #undefined, 9 = No answer/default

Physical exam findings

PEWARTS

N

1

S

Was there a genital wart on physical exam?

0 = No, 1 = Yes, 9 = No answer, not asked, refused, default

GW treatment provider

GWTXPROV

N

2

S

Were any of these treatments administered by the provider for genital warts?

0 = No treatment given by provider, 1= Excision, 2 = Cryotherapy, 3 = Podophyllin, 4 = Trichloroacetic or bicholoroacetic acid (TCA or BCA), 5 = Intralesional interferon, 6 = Laser surgery, 8 = Other, 9 = No answer/default, 11 = Cryotherapy & Podophyllin, 12 = Cryotherapy & Trichloroacetic acid

GW treatment patient

GWTXPT

N

1

S

Were any of these treatments prescribed or given to the patient for self-treatment of genital warts?

0 = No prescription or medications given to patient for self-treatment, 3 = Podofilox (Condylox), 4 = Green tea extracts, 7 = Imiquimod (Aldara), 8 = Other, 9 = Unknown/default

STD history

TRICHEVER

N

4

S

Haver you ever been diagnosed with Trich?

0 = No, 1 = Yes, 9 = No/answer/default

Patient symptoms

SXTRICH

N

1

S

Do you have either vaginal discharge, odor or itching?

0 = No, 1 = Yes, 9 = No answer, not asked, refused, default

Physical exam findings

PEDISCHARGE

N

1

S

Was there discharge on physical exam?

0 = No, 1 = Yes, 9 = No answer, not asked, refused, default

Care seeking behavior

DAYSTOCARE

N

3

S

How many days did you have your symptoms before you sought medical care?

0 = none/same day, 888 = Did not have symptoms, 999 = unknown/noanswer/default

Patient symptoms

SXUROGENITAL

N

1

S

Do you have any urogenital symptoms today?

0 = No, 1 = Yes, 9 = No answer, not asked, refused, default

 

SXRECTAL

N

1

S

Do you have any rectal symptoms today?

0 = No, 1 = Yes, 9 = No answer, not asked, refused, default

 

SXPHARYNGEAL

N

1

S

Do you have any pharyngeal symptoms (e.g., a sore throat) today?

0 = No, 1 = Yes, 9 = No answer, not asked, refused, default

Anonymous sex partners

ANONSEX12

N

1

S

Have you had sex with anyone in the past 12 months that you would not be able to contact again?

0 = No, 1 = Yes, 9 = No answer/default

Internet

INTERNET12

N

1

S

Have you met sex partners through the Internet in the past 12 months?

0 = No, 1 = Yes, 9 = No answer/default

Commercial sex

EXCHANGESEX12

N

1

S

Have you given or received drugs or money for sex in the past 12 months?

0 = No, 1 = Yes, 9 = No answer/default

Condom use

CONDOM

N

1

S

Did you use a condom at last intercourse?

0 = No, 1 = Yes, 9 = No answer/default

Drug use

IVDU12

N

1

S

Have you injected drugs in past 12 months?

0 = No, 1 = Yes, 9 = No answer/default

 

COCCRACK12

N

1

S

Have you used crack or cocaine in past 12 months?

0 = No, 1 = Yes, 9 = No answer/default

 

METH12

N

1

S

Methamphetamines?

0 = No, 1 = Yes, 9 = No answer/default

 

NITRATES12

N

1

S

Nitrates/poppers?

0 = No, 1 = Yes, 9 = No answer/default

 

PERFDRUG12

N

1

S

Sexual performance enhancing drugs such as Viagra (sildenafil)?

0 = No, 1 = Yes, 9 = No answer/default/not applicable

 

HEROIN12

N

1

S

Heroin?

0 = No, 1 = Yes, 9 = No answer/default

Exam findings

EXAM

N

1

S

Were there any abnormal findings during the physical exam?

0 = No, 1 = Yes, 9 = No answer, not asked, refused, default

 

PEULCER

N

1

S

Was there an ulcer or blister on physical exam?

0 = No, 1 = Yes, 9 = No answer, not asked, refused, default

 

PERASH

N

1

S

Was there a rash on physical exam?

0 = No, 1 = Yes, 9 = No answer, not asked, refused, default

 

PECMTADTEND

N

1

S

Was there cervical motion or adnexal tenderness on physical exam?

0 = No, 1 = Yes, 9 = No answer, not asked, refused, default

 

PECERVICITIS

N

1

S

Was there cervicitis on physical exam?

0 = No, 1 = Yes, 9 = No answer, not asked, refused, default

 

PEPHARYNX

N

1

S

Was there pharyngitis on physical exam?

0 = No, 1 = Yes, 9 = No answer, not asked, refused, default

 

PEPROCTITIS

N

1

S

Was there proctitis on physical exam?

0 = No, 1 = Yes, 9 = No answer, not asked, refused, default

Census tract of patient address

TRACT

C

11

S

What census tract does the patient reside in?

U.S. Census tract, code first 5 digits if only state/county known, code first 2 digits if only state known, leave blank if all unknown

Accuracy of patient address

ACCURACY

N

2

S

How accurate is the geocoded data on this patient?

1=Close (based on direct street segment, parcel, or longitude/latitude match), 2=Approximate (modification of address required to match to street segment), 3 = Very approximate (based only on zip or city centroid), 4=Not-geocodable (insufficient data to geocode, PO Box, General Delivery), 9 =Missing (no address available)

Education

EDUCATION

N

1

S

What is the highest level of education that you have completed?

1 = less than HS grad/GED, 2=HS grad/GED, 3= Some college, 4= 4 year college or more, 9 = unknown/no answer/default

Employment status

STUDENT

N

1

S

Are you a student at this time?

0 = No, not a student, 1 = Yes, full-time student, 2= Yes, part-time student, 9 = No answer/default

 

EMPLOY

N

1

S

What is your employment status at this time?

1= Employed, 2 = Self-employed, 3 = Out of work for more than 1 year, 4 = Out of work for less than 1 year, 5 = Homemaker, 6 = Retired, 7 = Unable to work, 9 = No answer/default

Incarceration

INCARC12

N

1

S

Have you been in jail or prison in the past 12 months?

0 = No, 1 = Yes, 9 = No answer/default

 

INCARCPART12

N

1

S

Have you had sex in the past 12 months with a partner who has been in jail or prison recently?

0 = No, 1 = Yes, 9 = No answer/default

STD history

GCEVER

N

1

S

Haver you ever been diagnosed with GC?

0 = No, 1 = Yes, 9 = No/answer/default

 

CTEVER

N

4

S

Haver you ever been diagnosed with CT?

0 = No, 1 = Yes, 9 = No/answer/default

 

SYPHEVER

N

2

S

Haver you ever been diagnosed with syphilis?

0 = No, 1 = Yes, 9 = No/answer/default

STD contact

STDCONT

N

1

S

Are you seeking care today because you have a sex partner with an STD?

0 = No, 1 = Yes, 9 = No answer, not asked, refused, default



11

File Typeapplication/msword
File TitleAttachment 3
Authorsvp8
Last Modified Byshari steinberg
File Modified2009-08-26
File Created2009-08-25

© 2024 OMB.report | Privacy Policy