Form CDC 73.60-C Rev 08 CDC 73.60-C Rev 08 Form 3: Control Strain Susceptability Testing

Gonococcal Isolate Surveillance Project
Form 3: Control Strain Susceptibility Testing

Regional Laboratory: (3 letter code)

Strain #

Control
ID

( SEE CODING INSTRUCTIONS ON BACK )

A

F-18

A

F-28

A

SPL-4

A

P681E

A

CDC 10328

A

CDC 10329

A

SPJ-15

B

F-18

B

F-28

B

SPL-4

B

P681E

B

CDC 10328

B

CDC 10329

B

SPJ-15

C

F-18

C

F-28

C

SPL-4

C

P681E

C

CDC 10328

C

CDC 10329

C

SPJ-15

D

F-18

D

F-28

D

SPL-4

D

P681E

D

CDC 10328

D

CDC 10329

D

SPJ-15

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

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

Pen

Tet

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)

___ / ___ / ______

1(P)

2(N)

___ / ___ / ______

1(P)

2(N)

___ / ___ / ______

1(P)

2(N)

___ / ___ / ______

Public reporting burden of this collection of information is estimated to average 12 minutes per run of 7 control strains (for a total monthly burden of 48 minutes per laboratory respondent), which includes the time required for transcribing the data from existing laboratory
records. 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-C Rev 08-2014 (FRONT)

Gonococcal Isolate Surveillance Project / Form 3: Control Strain Susceptibility Testing

Coding Instructions
Regional Laboratory Codes:
EMO

Atlanta — Emory University

AUS

Austin — Texas Department of State Health Services

JHU

Baltimore — Johns Hopkins University

UAB

Birmingham — University of Alabama at Birmingham

UWA

Seattle — University of Washington

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.

CDC 73.60-C Rev 08-2014 (BACK)

Gonococcal Isolate Surveillance Project / Form 3: Control Strain Susceptibility Testing