Form CDC 73.60-B Rev 08 CDC 73.60-B Rev 08 Form 2: Antimicrobial Susceptablity Testing

Gonococcal Isolate Surveillance Project
Form 2: Antimicrobial Susceptibility Testing

Sentinel Site: (3 letter code)
Specimens collected during:

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

Form Approved OMB No. 0920-0307 Exp. 08 / 31 / 2016

MICs (μg/ml) to Antimicrobial Agents
ß-Lac

Pen

Tet

Month

Gen

Cfx

Cro

Cip

Azi

Opt

Date tested
(mm/dd/yyyy)

1(P)

2(N)

___ /___ /_____

1(P)

2(N)

___ /___ /_____

1(P)

2(N)

___ /___ /_____

1(P)

2(N)

___ /___ /_____

1(P)

2(N)

___ /___ /_____

1(P)

2(N)

___ /___ /_____

1(P)

2(N)

___ /___ /_____

1(P)

2(N)

___ /___ /_____

1(P)

2(N)

___ /___ /_____

1(P)

2(N)

___ /___ /_____

1(P)

2(N)

___ /___ /_____

1(P)

2(N)

___ /___ /_____

1(P)

2(N)

___ /___ /_____

1(P)

2(N)

___ /___ /_____

1(P)

2(N)

___ /___ /_____

1(P)

2(N)

___ /___ /_____

1(P)

2(N)

___ /___ /_____

1(P)

2(N)

___ /___ /_____

1(P)

2(N)

___ /___ /_____

1(P)

2(N)

___ /___ /_____

1(P)

2(N)

___ /___ /_____

1(P)

2(N)

___ /___ /_____

1(P)

2(N)

___ /___ /_____

1(P)

2(N)

___ /___ /_____

1(P)

2(N)

___ /___ /_____

Control
ID

Isolate
#

( SEE CODING INSTRUCTIONS ON BACK )

Year

Public reporting burden of this collection of information is estimated to average 1 hour per client record extracted (for a total monthly burden of 121 hours per laboratory respondent), which includes the time required for laboratory processing of the client’s
isolate, 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 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, Atlanta, GA 30333,
ATTN: PRA (0920-0307). Do not send the completed form to this address.

CDC 73.60-B Rev. 08-2014 (FRONT)

Gonococcal Isolate Surveillance Project / Form 2: Antimicrobial Susceptibility Testing

Sentinel site codes

Coding Instructions
Sentinel site codes

Albuquerque

ALB

Los Angeles

LAX

Atlanta

ATL

Minneapolis

MIN

Birmingham

BHM

New Orleans

NOR

Boston

BOS

New York City

NYC

Buffalo

BUF

Orange County

ORA

Chicago

CHI

Philadelphia

PHI

Cleveland

CLE

Phoenix

PHX

Columbus

COL

Pontiac

PON

Dallas

DAL

Portland

POR

Greensboro

GRB

San Diego

SDG

Honolulu

HON

San Francisco

SFO

Indianapolis

IND

Seattle

SEA

Kansas City

KCY

Tripler

TRP

Las Vegas

LVG

Specimens
collected during:

Enter all four digits of the year, followed by the two digit code corresponding to the month
(01 for January, 02 for February, etc) in which the specimens were collected.

ß-Lac:

(ß--lactamase test) Check the appropriate box.
1 = positive
2 = negative

Pen:

(penicillin MIC)
Valid dilutions: 0.008, 0.015, 0.03, 0.06, 0.125, 0.25, 0.5, 1.0, 2.0, 4.0, 8.0, 16.0, 32.0, 64.0

Tet:

(tetracycline MIC)
Valid dilutions: 0.06, 0.125, 0.25, 0.5, 1.0, 2.0, 4.0, 8.0, 16.0, 32.0, 64.0

Gen:

(gentamicin MIC)
Valid dilutions: 1.0, 2.0, 4.0, 8.0, 16.0, 32.0

Cfx:

(cefixime MIC)
Valid dilutions: 0.002, 0.004, 0.008, 0.015, 0.03, 0.06, 0.125, 0.25, 0.5, 1.0, 2.0

Cro:

(ceftriaxone MIC)
Valid dilutions: 0.001, 0.002, 0.004, 0.008, 0.015, 0.03, 0.06, 0.125, 0.25, 0.5, 1.0, 2.0

Cip:

(ciprofloxacin MIC)
Valid dilutions: 0.001, 0.002, 0.004, 0.008, 0.015, 0.03, 0.06, 0.125, 0.25, 0.5, 1.0, 2.0, 4.0, 8.0, 16.0

Azi:

(azithromycin MIC)
Valid dilutions: 0.008, 0.015, 0.03, 0.06, 0.125, 0.25, 0.5, 1.0, 2.0, 4.0, 8.0, 16.0, 32.0, 64.0, 128.0, 256.0

Opt:

(optional agent)

Date tested:

(mm/dd/yyyy)
Enter month, day, and year of isolate testing.

Control ID:

Corresponds to the Control ID batch on Form 3: Control Strain Susceptibility Testing.
Valid options are A, B, C, or D.

CDC 73.60-B Rev. 08-2014 (BACK)

Gonococcal Isolate Surveillance Project / Form 2: Antimicrobial Susceptibility Testing