Form CDC73.60A Form 1: Demographic/Clinical Data

Gonococcal Isolate Surveillance Project
Form 1: Demographic/Clinical Data

Sentinel Site: (3 letter code) _____ _____ _____
(2-4)

Specimens collected during: ____ ____ ____ ____ ____ ____

(1)

( SEE CODING INSTRUCTIONS ON BACK )

01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

(32)

(33)

(34)

(35)

(36)

(37-46)

(47-56)

___ ___/___ ___/___ ___ ___ ___

___ ___/___ ___/___ ___ ___ ___

___ ___/___ ___/___ ___ ___ ___

___ ___/___ ___/___ ___ ___ ___

___ ___/___ ___/___ ___ ___ ___

___ ___/___ ___/___ ___ ___ ___

___ ___/___ ___/___ ___ ___ ___

___ ___/___ ___/___ ___ ___ ___

___ ___/___ ___/___ ___ ___ ___

___ ___/___ ___/___ ___ ___ ___

___ ___/___ ___/___ ___ ___ ___

___ ___/___ ___/___ ___ ___ ___

___ ___/___ ___/___ ___ ___ ___

___ ___/___ ___/___ ___ ___ ___

___ ___/___ ___/___ ___ ___ ___

___ ___/___ ___/___ ___ ___ ___

___ ___/___ ___/___ ___ ___ ___

___ ___/___ ___/___ ___ ___ ___

___ ___/___ ___/___ ___ ___ ___

___ ___/___ ___/___ ___ ___ ___

___ ___/___ ___/___ ___ ___ ___

___ ___/___ ___/___ ___ ___ ___

___ ___/___ ___/___ ___ ___ ___

___ ___/___ ___/___ ___ ___ ___

___ ___/___ ___/___ ___ ___ ___

___ ___/___ ___/___ ___ ___ ___

___ ___/___ ___/___ ___ ___ ___

___ ___/___ ___/___ ___ ___ ___

___ ___/___ ___/___ ___ ___ ___

___ ___/___ ___/___ ___ ___ ___

___ ___/___ ___/___ ___ ___ ___

___ ___/___ ___/___ ___ ___ ___

___ ___/___ ___/___ ___ ___ ___

___ ___/___ ___/___ ___ ___ ___

___ ___/___ ___/___ ___ ___ ___

___ ___/___ ___/___ ___ ___ ___

___ ___/___ ___/___ ___ ___ ___

___ ___/___ ___/___ ___ ___ ___

___ ___/___ ___/___ ___ ___ ___

___ ___/___ ___/___ ___ ___ ___

___ ___/___ ___/___ ___ ___ ___

___ ___/___ ___/___ ___ ___ ___

___ ___/___ ___/___ ___ ___ ___

___ ___/___ ___/___ ___ ___ ___

___ ___/___ ___/___ ___ ___ ___

___ ___/___ ___/___ ___ ___ ___

___ ___/___ ___/___ ___ ___ ___

___ ___/___ ___/___ ___ ___ ___

___ ___/___ ___/___ ___ ___ ___

___ ___/___ ___/___ ___ ___ ___

(57-58)

(59)

(60)

(61)

(62)

(63-64)

(Sum of the two)

st
at
Tr
us
av
el
hi
Se
x w stor
y
or
k
P
an rev exp
i
o
tib ou
su
re
ID iotics
U
us
e
No
nID
U
T
(g rea
on tm
or en
rh t 1
ea
)

Date of birth
(mm/dd/yyyy)

e

Date of
clinic visit
(mm/dd/yyyy)

Total episodes:
(20-22)

Zipcode
(65-69)

(70)

(71)

(72)

(73)

(74)

(75)

(76-77)

Other
treatment 1
(78-88)

(23-25)

T
(c rea
hl tm
am e
yd nt 2
ia
)

Male:
(17-19)

HI
V

(31)

Female:

(15-16)

S
o r ex u
ie al
nt
Sy atio
n
m
pt
Re om
s
as
o
Pr n f
g o ev o r
no iou vis
rrh s
it
ea hx
#
of
ep of
(
e
ve
(p is pre
r
as od v
t 1 es iou )
2
s
m
os
.)

hn
i
A cit
/A me y
la ric
s
As kanan I
n
ia
n Nat dia
iv n
Bl
e
ac
k
N
/P ativ
ac e
i
W fic IHaw
hi
te slanaiia
de n
Ot
r
he
r

Patient #

in
ic
Se
x

Cl

Et
(30)

Number of gonorrhea episodes diagnosed:

___ ___ ___ ___ ___ ___
(11-14)

(29)

(9-10)

Month

Ag

Year

(28)

Month

(5-8)

03/31/2011
Form approved OMB no. 0920-0307 exp.1/31/2008

Corresponding date (yyyy/mm)
of clinic totals for gonorrhea:

(2627)

Year

(89-90)

Public reporting burden for this collection of information is estimated to average 11 minutes per client record extracted (for a total monthly burden of 3 hours and 30 minutes per clinic respondent), which includes the time required 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 person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this
D-74 Atlanta, GA 30333, ATTN: PRA (0920-0307). Do not send the completed form to this address.
burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC, Project Clearance Officer, 1600 Clifton Road, MS E-11,
CDC 73.60A Rev. 11/2005

COPY 1 – CDC

Gonococcal Isolate Surveillance Project / Form 1: Demographic/Clinical Data

Gonococcal Isolate Surveillance Project
Form 1: Demographic/Clinical Data

Sentinel Site: (3 letter code) _____ _____ _____
(2-4)

Specimens collected during: ____ ____ ____ ____/____ ____

(1)

( SEE CODING INSTRUCTIONS ON BACK )

26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50

(32)

(33)

(34)

(35)

(36)

(37-46)

(47-56)

___ ___/___ ___/___ ___ ___ ___

___ ___/___ ___/___ ___ ___ ___

___ ___/___ ___/___ ___ ___ ___

___ ___/___ ___/___ ___ ___ ___

___ ___/___ ___/___ ___ ___ ___

___ ___/___ ___/___ ___ ___ ___

___ ___/___ ___/___ ___ ___ ___

___ ___/___ ___/___ ___ ___ ___

___ ___/___ ___/___ ___ ___ ___

___ ___/___ ___/___ ___ ___ ___

___ ___/___ ___/___ ___ ___ ___

___ ___/___ ___/___ ___ ___ ___

___ ___/___ ___/___ ___ ___ ___

___ ___/___ ___/___ ___ ___ ___

___ ___/___ ___/___ ___ ___ ___

___ ___/___ ___/___ ___ ___ ___

___ ___/___ ___/___ ___ ___ ___

___ ___/___ ___/___ ___ ___ ___

___ ___/___ ___/___ ___ ___ ___

___ ___/___ ___/___ ___ ___ ___

___ ___/___ ___/___ ___ ___ ___

___ ___/___ ___/___ ___ ___ ___

___ ___/___ ___/___ ___ ___ ___

___ ___/___ ___/___ ___ ___ ___

___ ___/___ ___/___ ___ ___ ___

___ ___/___ ___/___ ___ ___ ___

___ ___/___ ___/___ ___ ___ ___

___ ___/___ ___/___ ___ ___ ___

___ ___/___ ___/___ ___ ___ ___

___ ___/___ ___/___ ___ ___ ___

___ ___/___ ___/___ ___ ___ ___

___ ___/___ ___/___ ___ ___ ___

___ ___/___ ___/___ ___ ___ ___

___ ___/___ ___/___ ___ ___ ___

___ ___/___ ___/___ ___ ___ ___

___ ___/___ ___/___ ___ ___ ___

___ ___/___ ___/___ ___ ___ ___

___ ___/___ ___/___ ___ ___ ___

___ ___/___ ___/___ ___ ___ ___

___ ___/___ ___/___ ___ ___ ___

___ ___/___ ___/___ ___ ___ ___

___ ___/___ ___/___ ___ ___ ___

___ ___/___ ___/___ ___ ___ ___

___ ___/___ ___/___ ___ ___ ___

___ ___/___ ___/___ ___ ___ ___

___ ___/___ ___/___ ___ ___ ___

___ ___/___ ___/___ ___ ___ ___

___ ___/___ ___/___ ___ ___ ___

___ ___/___ ___/___ ___ ___ ___

___ ___/___ ___/___ ___ ___ ___

(57-58)

(59)

(60)

(61)

(62)

(63-64)

(Sum of the two)

st
at
Tr
us
av
el
hi
Se
x w stor
y
or
k
P
an rev exp
i
o
tib ou
su
re
ID iotics
U
us
e
No
nID
U
T
(g rea
on tm
or en
rh t 1
ea
)

Date of birth
(mm/dd/yyyy)

e

Date of
clinic visit
(mm/dd/yyyy)

Total episodes:
(20-22)

Zipcode
(65-69)

(70)

(71)

(72)

(73)

(74)

(75)

(76-77)

Other
treatment 1
(78-88)

(23-25)

T
(c rea
hl tm
am e
yd nt 2
ia
)

Male:
(17-19)

HI
V

(31)

Female:

(15-16)

S
o r ex u
ie al
nt
Sy atio
n
m
pt
Re om
s
as
o
Pr n f
g o ev o r
no iou vis
rrh s
it
ea hx
#
of
ep of
(
e
ve
(p is pre
r
as od v
t 1 es iou )
2
s
m
os
.)

hn
i
A cit
/A me y
la ric
s
As kanan I
n
ia
n Nat dia
iv n
Bl
e
ac
k
N
/P ativ
ac e
i
W fic IHaw
hi
te slanaiia
de n
Ot
r
he
r

Patient #

in
ic
Se
x

Cl

Et
(30)

Number of gonorrhea episodes diagnosed:

___ ___ ___ ___/___ ___
(11-14)

(29)

(9-10)

Month

Ag

Year

(28)

Month

(5-8)

Form approved OMB no. 0920-0307 exp.1/31/2008

Corresponding date (yyyy/mm)
of clinic totals for gonorrhea:

(2627)

Year

(89-90)

Public reporting burden for this collection of information is estimated to average 11 minutes per client record extracted (for a total monthly burden of 3 hours and 30 minutes per clinic respondent), which includes the time required 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 person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this
D-74 Atlanta, GA 30333, ATTN: PRA (0920-0307). Do not send the completed form to this address.
burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC, Project Clearance Officer, 1600 Clifton Road, MS E-11,
CDC 73.60A Rev. 11/2005

COPY 1 – CDC

Gonococcal Isolate Surveillance Project / Form 1: Demographic/Clinical Data