Form no form number no form number Information Content of Nationally STD Case Report by Dat

Attachment 3

OMB# 0920-0819

Information Content of Nationally Notifiable STD Case Report by Data Element

Table 1

Data Element Name	Data Element Definition
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).
Method of Case Detection	How did the case patient first come to the attention of the health department for this condition?
ZIP	5-digit Zip code of residence of the case patient.
Pregnant - initial exam	Was the case patient pregnant at time of initial exam for the condition reported in this case report?
Specimen source	Anatomic site or specimen type from which positive lab specimen was collected.
Date of laboratory specimen collection	Date of collection of initial laboratory specimen used for diagnosis of health event reported in this case report.
Neurological involvement?	If event = some stage of syphilis, does the patient have neurologic involvement based on current case definition?
American Indian/Alaska native?	Case patient reported Am Indian/Alaska Native (AI/AN) race
Asian?	Case patient reported Asian race
Black/African American?	Case patient reported Black/African American (B) race
Native Hawaiian/Pacific Islander?	Case patient reported Native Hawaiian/Pacific Island (NH/PI) race
White?	Case patient reported White (W) race
Other race?	Case patient reported some other race (not AI/NA, Asian, Black, NH/PI, White)
Refused to report race	Case patient refused to report race
Unknown race	Case patient could not answer this question for any reason
Hispanic/Latino?	Indicator for case-patient's Hispanic/Latino ethnicity.
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.
STD IMPORT	Was case imported? Was disease acquired elsewhere? Indicates probable location of disease acquisition relative to reporting state.
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.
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).
Treatment date	Date treatment initiated for the condition that is the subject of this case report.
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.
HIV status?	Documented or self-reported HIV status at the time of event.
Had sex with a male within past 12 months?
Had sex with a female within past 12 months?
Had sex with an anonymous partner within past 12 months?
Had sex with a person known to him/her to be an IDU within past 12 months?
Had sex while intoxicated and/or high on drugs within past 12 months?
Exchanged drugs/money for sex within past 12 months?
Had sex with a person who is known to her to be an MSM within past 12 months?	NOTE: For women only.
Engaged in injection drug use within past 12 months?
During the past 12 months, which of the following injection or non-injection drugs have been used?
Crack	A potent, relatively cheap, addictive variety of cocaine; often a rock, usually smoked through a crack-pipe (synonyms: rock, rock cocaine).
Cocaine	A stimulant narcotic in the form of a white powder that users generally self-administer by insufflation through the nose (synonyms: coke, snow, blow).
Heroin	An addictive, narcotic drug derived from opium (synonyms: horse, junk, smack).
Methamphetamines	A highly addictive phenethylamine stimulant drug (synonyms: ice, crystal, meth).
Nitrates/Poppers	Any one of various alkyl nitrites (particularly amyl nitrite, butyl nitrite and isobutyl nitrite) taken for recreational purposes through direct inhalation.
Erectile dysfunction (ED) medications	Any one of several drugs available by prescription (e.g.Viagra) used to treat erectile dysfunction.
Other drug(s) used?	Other drug = type of injection or non-injection drug used for recreational purposes that is not listed above.
No drug use reported
Been incarcerated within past 12 months?
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?
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?
Total number of sex partners last 12 months?	Total number of claimed sex partners that the case patient has had in the last 12 months. Total partners equal the sum of all male, female, and transgender partners during the last 12 months. Those marked unknown or refused are excluded from the total.
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	One or more lesion(s) indicative of syphilis were present in the anus or rectum.
B=Penis	One or more lesion(s) indicative of syphilis were present on the penis.
C=Scrotum	One or more lesion(s) indicative of syphilis were present on the scrotum.
D=Vagina	One or more lesion(s) indicative of syphilis were present in the vagina.
E=Cervix	One or more lesion(s) indicative of syphilis were present on the cervix.
F=Nasopharynx	One or more lesion(s) indicative of syphilis were present in the nasopharynx.
G=Mouth/Oral cavity	One or more lesion(s) indicative of syphilis were present in the mouth or oral cavity.
H=Eye/conjunctiva	One or more lesion(s) indicative of syphilis were present on the eye or conjunctiva.
I=Head	One or more lesion(s) indicative of syphilis were present on the head.
J=Torso	One or more lesion(s) indicative of syphilis were present on the torso.
K=Extremities (Arms, legs, feet, hands)	One or more lesion(s) indicative of syphilis were present on the extremities (arms, legs, feet, hands).
N= No lesion noted	Patient was evaluated but no lesion(s) indicative of syphilis were observed.
O=Other anatomic site not represented in other defined anatomic sites	One or more lesion(s) indicative of syphilis were present in some other anatomic site not represented in the defined anatomic sites.
U=Unknown	Anatomic site of lesion information is not available for whatever reason, e.g. patient not evaluated or information is not available for data entry.
Type of nontreponemal 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?
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)
NETSS Version	What version of the NETSS record layout are you providing? i.e. Version 3 (January 2011)

Table 2

Data Element Name	Data Element Definition
RECORD TYPE	Record type will determine how the record is handled when it arrives at CDC.
STATE	State reporting case information & jurisdiction of case (based on patient residence).
YEAR	MMWR Year for which case information was reported to CDC. Derived from MMWR week.
CASE REPORT ID	Unique Case Report ID (numeric) assigned by the state.
SITE CODE	Location code assigned by the state to indicate where report originated and who has responsibility for maintaining the record.
WEEK	MMWR Week on Surveillance Calendar, i.e., week for which case information is reported to CDC. Assigned by reporting jurisdiction.
EVENT or DIAGNOSIS	STD or associated syndrome (health event) for which the case-patient has been diagnosed (regardless of case status per CSTE/CDC surveillance case definition).
COUNT	Represents # of cases reported in this 'record'; supports aggregate- (when > 1) or case-specific (when =1) reporting.
COUNTY	Standard FIPS code for county of case-patient's residence in reporting state.
DATE OF BIRTH	Date of birth of case-patient in YYYYMMDD format.
AGE	Age of case-patient at time of initial exam or specimen collection for case report "condition".
AGETYPE	Indicates the units (years, months, etc.) for the AGE field.
SEX	Current sex of patient
EVENT DATE	Date of disease in YYMMDD format. This date depends upon how case dates are assigned in the STD program, i.e., date could be the onset of symptoms date, diagnosis date, laboratory result date, date case first recognized and/or reported to STD program, or date case reported to CDC.
DATETYPE	Describes the type of date provided in EVENT DATE.
CASE STATUS	Status of the case/event as suspect, probable, or confirmed.
OUTBREAK	Indicates whether the case was associated with an outbreak.
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).
Method of Case Detection	How did the case patient first come to the attention of the health department for this condition?
ZIP	5-digit Zip code of residence of the case patient.
Pregnant - initial exam	Was the case patient pregnant at time of initial exam for the condition reported in this case report?
Specimen source	Anatomic site or specimen type from which positive lab specimen was collected.
Date of laboratory specimen collection	Date of collection of initial laboratory specimen used for diagnosis of health event reported in this case report.
Neurological involvement?	If event = some stage of syphilis, does the patient have neurologic involvement based on current case definition?
American Indian/Alaska native?	Case patient reported Am Indian/Alaska Native (AI/AN) race
Asian?	Case patient reported Asian race
Black/African American?	Case patient reported Black/African American (B) race
Native Hawaiian/Pacific Islander?	Case patient reported Native Hawaiian/Pacific Island (NH/PI) race
White?	Case patient reported White (W) race
Other race?	Case patient reported some other race (not AI/NA, Asian, Black, NH/PI, White)
Refused to report race	Case patient refused to report race
Unknown race	Case patient could not answer this question for any reason
Hispanic/Latino?	Indicator for case-patient's Hispanic/Latino ethnicity.
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.
STD IMPORT	Was case imported? Was disease acquired elsewhere? Indicates probable location of disease acquisition relative to reporting state.
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.
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).
Treatment date	Date treatment initiated for the condition that is the subject of this case report.
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.
HIV status?	Documented or self-reported HIV status at the time of event.
Had sex with a male within past 12 months?
Had sex with a female within past 12 months?
Had sex with an anonymous partner within past 12 months?
Had sex with a person known to him/her to be an IDU within past 12 months?
Had sex while intoxicated and/or high on drugs within past 12 months?
Exchanged drugs/money for sex within past 12 months?
Had sex with a person who is known to her to be an MSM within past 12 months?	NOTE: For women only.
Engaged in injection drug use within past 12 months?
During the past 12 months, which of the following injection or non-injection drugs have been used?
Crack	A potent, relatively cheap, addictive variety of cocaine; often a rock, usually smoked through a crack-pipe (synonyms: rock, rock cocaine).
Cocaine	A stimulant narcotic in the form of a white powder that users generally self-administer by insufflation through the nose (synonyms: coke, snow, blow).
Heroin	An addictive, narcotic drug derived from opium (synonyms: horse, junk, smack).
Methamphetamines	A highly addictive phenethylamine stimulant drug (synonyms: ice, crystal, meth).
Nitrates/Poppers	Any one of various alkyl nitrites (particularly amyl nitrite, butyl nitrite and isobutyl nitrite) taken for recreational purposes through direct inhalation.
Erectile dysfunction (ED) medications	Any one of several drugs available by prescription (e.g.Viagra) used to treat erectile dysfunction.
Other drug(s) used?	Other drug = type of injection or non-injection drug used for recreational purposes that is not listed above.
No drug use reported
Been incarcerated within past 12 months?
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?
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?
Total number of sex partners last 12 months?	Total number of claimed sex partners that the case patient has had in the last 12 months. Total partners equal the sum of all male, female, and transgender partners during the last 12 months. Those marked unknown or refused are excluded from the total.
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	One or more lesion(s) indicative of syphilis were present in the anus or rectum.
B=Penis	One or more lesion(s) indicative of syphilis were present on the penis.
C=Scrotum	One or more lesion(s) indicative of syphilis were present on the scrotum.
D=Vagina	One or more lesion(s) indicative of syphilis were present in the vagina.
E=Cervix	One or more lesion(s) indicative of syphilis were present on the cervix.
F=Nasopharynx	One or more lesion(s) indicative of syphilis were present in the nasopharynx.
G=Mouth/Oral cavity	One or more lesion(s) indicative of syphilis were present in the mouth or oral cavity.
H=Eye/conjunctiva	One or more lesion(s) indicative of syphilis were present on the eye or conjunctiva.
I=Head	One or more lesion(s) indicative of syphilis were present on the head.
J=Torso	One or more lesion(s) indicative of syphilis were present on the torso.
K=Extremities (Arms, legs, feet, hands)	One or more lesion(s) indicative of syphilis were present on the extremities (arms, legs, feet, hands).
N= No lesion noted	Patient was evaluated but no lesion(s) indicative of syphilis were observed.
O=Other anatomic site not represented in other defined anatomic sites	One or more lesion(s) indicative of syphilis were present in some other anatomic site not represented in the defined anatomic sites.
U=Unknown	Anatomic site of lesion information is not available for whatever reason, e.g. patient not evaluated or information is not available for data entry.
Type of nontreponemal 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?
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)
NETSS Version	What version of the NETSS record layout are you providing? i.e. Version 3 (January 2011)