Att 3b - Population-based data elements

Form Approved

OMB No. 0920-0842

Expiration Date XX/XX/20XX

Population Based Surveillance

Data Elements

Public Reporting burden of this collection of information is estimated to average 8 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 (N= numeric, C= character)	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, 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, 8=Pending interview, 9 = Unknown/default, 10 = No response to contact attempts, 11 = No or insufficient contact information
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), 888= out of state, 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 M to F, 4=Transgender F to M, 5=Transgender unspecified, 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
Insurance Questions	ClinicCare	N	1	R	At the time you were tested for gonorrhea, what was the main reason that you sought care from the provider who tested you?	1 = It was my usual place for medical care, 2= Ability to do walk in/same day appt, 3= Costs less, 4= Privacy concerns, 5= Expert care, 6 = Other, please specify (if they choose this go to free text field)
	OtherCare	C	50	R	Free text field to put in Other from the previous question.	Free text field
	HealthIns	N	1	R	Do you have any kind of health care coverage or insurance?	0 = No, 1 = Yes, 3= Refused, 8 = Don't know/not sure
	TypeIns	N	1	R	Is your insurance a private health insurance or publically-funded health insurance, such as Medicaid or insert name of the state health plan related to Medicaid or CHIP?	1 = Private health insurance, 2= Government health insurance, 3= Refused, 8= Don't know/not sure
	Copay	N	1	R	Did you have to pay a co-pay when you were diagnosed with gonorrhea?	0 = No, 1 = Yes, 3= Refused, 8 = Don't know/not sure