Population-based Surveillance

STD Surveillance Network (SSuN)

SSuN_Attachment 3B_Population Based Surveillance

Population-based Surveillance

OMB: 0920-0842

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SSuN Variable List

Population-Based Surveillance:

Data Elements



Attachment 3b



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


Population Based Surveillance Data Elements

Public reporting burden of this collection of information is estimated to average 7 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: OMB-PRA (0920-09XX)



Domain

Variable name

Type

Length

County R=Recommended O=Optional

Question

Response coding

State

STATE

N

2

R

What state is the patient being reported by?

Standard reporting state FIPS code, 99 = default

Survey county

COUNTY

N

3

R

Which survey county submitted this patient's data?

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

Eligible for SSuN

ELIGIBLE

N

1

R

Is this patient eligible to be selected for SSuN?

0 = No, reported >60 days from specimen collection date, 1 = Yes, all others

Sampling fraction threshold

SAMPFRACT

N

3

R

What sample fraction threshold was used in the selection of this case?

Range: 1-100

Randomization number

RANDOM

N

3

R

What was the random number assigned to this patient?

Range: 1-100

Selected for SSuN

SELECT

N

1

R

Was this patient selected for inclusion in the SSuN random sample?

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

Interview date

INTDATE

Date

10

R

What day was the patient interviewed or did the patient fill out the questionnaire?

mm/dd/yyyy, blank = unknown/default

Interview status

INTSTAT

N

1

R

What was the final status of the attempt to administer the questionnaire to the patient?

0 = Patient contacted, interview completed, 1 = Patient contacted, interview refused, 2 = Patient contacted, partial interview, 3 = Unable to locate/lost to follow-up, no response to contact attempts, no or insufficient contact information, 4 = Patient contacted, interview not complete due to language barrier, 5 = Case is selected for a SSuN interview >60 days from specimen collection date, 6 = Case is found to be OOJ in the process of interviewing or obtaining contact information, 7 = Provider refused patient interview, 9 = Unknown/default

Interview method

INTTYPE

N

1

R

How were the data for the patient collected?

1 = In person interview, 2 = Telephone, 3 = Self-administered questionnaire, 9 = Unknown/default

Report date

REPDATE

Date

10

R

What date was the case reported to state/county?

mm/dd/yyyy, blank = unknown/default, REQUIRED FIELD FOR EVERY RECORD

Patient ID

PATIENTID

C

16

R

Unique patient identification number assigned by state

Locally defined, REQUIRED FIELD FOR EVERY RECORD

Event ID

EVENTID

C

18

R

Event identification number assigned by state

Locally defined, REQUIRED FIELD FOR EVERY RECORD

County of Residence

COUNTYRES

N

3

R

What county does the patient reside in?

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

Zip code

ZIP

C

5

R

What zipcode does the patient reside in?

99999 = missing

Census tract

TRACT

C

11

O

What census tract does the patient reside in?

99999999999 = non-geocodable or missing Do not partially code TRACT.

Accuracy of patient address

ACCURACY

N

2

O

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), 5=Data suppressed to protect confidentiality, 9 =Missing (no address available)

Age

AGE

N

2

R

How old are you?

Age in years, 99 = No answer/default

Sex

SEX

N

1

R

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

Hispanic

HISP

N

1

R

Are you of Hispanic ethnicity?

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

Race

AIAN

N

1

R

Are you American Indian or Alaska Native?

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

 

ASIAN

N

1

R

Are you Asian?

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

 

PIH

N

1

R

Are you Pacific Islander or Hawaiian?

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

 

BLACK

N

1

R

Are you Black?

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

 

WHITE

N

1

R

Are you White?

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

 

OTHERRACE

N

1

R

Are you another race not listed above?

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

Provider

PROVIDER

N

2

R

What type of clinic were you at when you were tested for gonorrhea? OR What type of clinic reported this episode of gonorrhea?

2 = STD Clinic

 

 

 

 

 

 

11 = Emergency Room/Urgent care

 

 

 

 

 

 

8 = Jail/Prison

 

 

 

 

 

 

5 = HIV Care Clinic

 

 

 

 

 

 

13 = Outreach

 

 

 

 

 

 

14 = Military

 

 

 

 

 

 

15 = School

 

 

 

 

 

 

6 = Family Planning/Gynecology/Reproductive health

 

 

 

 

 

 

17 = Private Provider/HMO

 

 

 

 

 

 

18 = Public clinic (not STD)/Community Health Center

 

 

 

 

 

 

12 = Hospital (other)

 

 

 

 

 

 

16 = Other

 

 

 

 

 

 

99 = No answer/default

STD clinic

STDCLINIC

N

1

R

Have you been to an STD clinic in the past year?

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

Education

EDUCATION

N

1

O

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

O

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

Employment status

EMPLOY

N

1

O

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

Patient symptoms

SYMPPT

N

1

R

In the 3 months before you were tested for gonorrhea, did you have any symptoms of gonorrhea (vaginal or penile discharge, burning with urination, abdominal pain, abnormal vaginal bleeding, testicular pain, anal symptoms, sore throat)?

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

Care seeking behavior

DAYSTOCARE

N

3

R

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

STD contact

STDCONT

N

1

R

At the time you were tested for gonorrhea, were you seeking care because you had a sex partner with an STD?

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

Pregnancy status

PREGNANT

N

1

R

At the time you were tested for gonorrhea, were you pregnant?

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

Sex of sex partners

MENSEX3

N

4

R*

In the 3 months before you were tested for gonorrhea, how many male sex partners did you have ?

#; 9999 = No answer, refused, default

 

FEMSEX3

N

4

R*

In the 3 months before you were tested for gonorrhea, how many female sex partners did you have ?

#; 9999 = No answer, refused, default


SEXOR3

N

1

R*

In the 3 months before you were tested for gonorrhea, did you have sex with men, women, or both ?

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

 

NUMSEX3

N

4

R*

How many sex partners dis you have in the 3 months before you were tested for gonorrhea?

#; 9999 = No answer, refused, default

 

SEXUALITY

N

1

O

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

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

Anonymous sex partners

ANONSEX12

N

1

R

In the 12 months before you were tested for gonorrhea, did you have sex with anyone that you would not be able to contact again?

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

Internet

INTERNET12

N

1

R

In the 12 months before you were tested for gonorrhea, did you meet sex partners through the Internet ?

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

Commercial sex

EXCHANGESEX12

N

1

R

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

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

Incarceration

INCARC12

N

1

R

In the 12 months before you were tested for gonorrhea, were you jail or prison?

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

 

INCARCPART12

N

1

R

In the 12 months before you were tested for gonorrhea, did you have sex with a partner who had been in jail or prison recently?

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

Drug use

IVDU12

N

1

R

In the 12 months before you were tested for gonorrhea, did you inject drugs?

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

 

COCCRACK12

N

1

R

Have you used crack or cocaine in past 12 months?

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

 

METH12

N

1

R

Methamphetamines?

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

 

NITRATES12

N

1

R

Nitrates/poppers?

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

 

PERFDRUG12

N

1

R

Sexual performance enhancing drugs such as Viagra (sildenafil)?

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

 

HEROIN12

N

1

R

Heroin?

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

Last partner

 

 

 

 

Think back to the last person you had sex with before you were tested for gonorrhea. The next questions are about this sex partner.

 

 

PARTAGE

N

2

R

How old was this sex partner?

Age in years, 99 = No answer/default

 

PARTSEX

N

1

R

Was this partner male, female, or transgender?

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

 

PARTETHN

N

1

R

Was this partner Hispanic?

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

 

PARTRACE

N

1

R

What was the race of this partner?

1 = American Indians or Alaska Native, 2 = Asian, 3 = Pacific Islander or Hawaiian, 4 = Black, 5 = White, 6 = Other race, 9 = Unknown/default

 

PARTHIV

N

1

R

Was this partner HIV positive?

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

 

PARTCOND

N

1

R

In the time before you weretested for gonorrrhea, did you use a condom the last time you had anal or vaginal sex with this partner?

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

 

PARTSINCE

N

1

R

Have you had sex with this partner since you were tested for gonorrhea?

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

 

PARTRX

N

1

R

How sure are you that this partner got treated?

1 = Sure partner got treated, 2 = Unsure, 3 = Sure partner did NOT get treated, 9 = Unknown/default

Partner services

PDPT

N

1

O

Were you given medication or a prescription to give to your partner(s)?

0 = No, 4 = No, partner already treated, 5 = Yes, 9 = Unknown/default

GC history

GCHX12

N

1

R

At the time you were tested for gonorrhea, had you had another episode of gonorrhea in the 12 months before that?

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

HIV history

HIVEVERTEST

N

1

R

Haver you ever been tested for HIV?

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

 

HIVDATE

C

7

R

When were you last tested for HIV?

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

 

HIVRESULTLAST

N

1

R

What was your last HIV test result?

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

PID history

PID

N

1

R

Were you told by your doctor that you had pelvic inflammatory disease, also known as PID?

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

CT Coinfection

CTCOINFECT

N

1

R

Was the patient coinfected with chlamydia at time of this gonorrhea episode?

0 = No, 1 = Yes, 9 = Unknown/not tested/results not available/default

GC Specimen collection date

SPECDATE

Date

10

R

What date was the gonococcal specimen collected?

mm/dd/yyyy, blank = unknown/default

GC test type

CULTURE

N

1

R

What was the result of the gonorrhea culture test?

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

 

NAAT

N

1

R

What was the result of the nucleic acid amplification test (NAAT)?

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

 

NONAMP

N

1

R

What was the result of the non-amplified nuceic acid test?

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

 

GRAM

N

1

R

What was the result of the gram stain?

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

 

OTHER

N

1

R

What was the result of any other type of gonorrhea test?

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

Treatment

TXDATE

Date

10

R

What date was medicine given for the treatment of gonorrhea?

mm/dd/yyyy, blank = unknown/default

Treatment 1

TX1

N

2

R

Were any of these drugs given for the treatment of gonorrhea?

00 = no treatment given, 10 = ceftriaxone (Rocephin), 11 = cefixime (Suprax), 12 = cefpodoxime proxetil (Vantin), 13 = cefoxitin (Mefoxin), 14 = ceftizoxime (Cefizox), 15 = cefotaxime (Claforan), 16 = cefuroxime axetil (Ceftin), 20 = ciprofloxacin (Cipro), 21 = levofloxacin (Levaquin), 22 = ofloxacin (Floxin), 23 = gatifloxacin (Tequin), 24 = norfloxacin (Noroxin), 25 = lomefloxacin (Maxaquin), 26 = gemifloxacin (Factive), 30 = spectinomycin (Trobicin), 31 = gentamicin (Garamycin), 40 = azithromycin (Zithromax), 88 = other, 99 = unknown/default

Dosage 1

DOSE1

N

4

O

What was the dosage in milligrams of the treatment given?

100, 125, 200, 240, 250, 280, 300, 400, 500, 800, 1000, 2000, 8888 = other, 9999 = unknown/default

Treatment 2

TX2

N

2

O

Were any of these drugs given for the treatment of chlamydia?

00 = no treatment given, 20 = ciprofloxacin (Cipro), 21 = levofloxacin (Levaquin), 22 = ofloxacin (Floxin), 40 = azithromycin (Zithromax), 41 = erythromycin, 51 = doxycycline, 88 = other, 99 = unknown/default

Dosage 2

DOSE2

N

4

O

What was the dosage in milligrams of the treatment given?

100, 125, 200, 250, 300, 400, 500, 800, 1000, 2000, 8888 = other, 9999 = unknown/default





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