Form CDC 73.60A CDC 73.60A Form 1: Demographic/Clinical Data

Gonococcal Isolate Surveillance Project
Form 1: Demographic /Clinical Data

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

Month

01

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02

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03

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04

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05

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06

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07

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08

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09

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10

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11

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12

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13

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14

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15

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16

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17

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18

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19

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20

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21

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22

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23

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24

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25

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Other
treatment 1

Treatment 2

Treatment 1 (gonorrhea)

Non-IDU

IDU

Previous antibiotic use

Sex work exposure

Travel history

HIV status

# of previous episodes
(past 12 mos.)

Previous hx of
gonorrhea (ever)

Symptoms

(mm/dd/yyyy)

Sexual orientation

Date of
Clinic Visit

Age

Other

White

Form approved OMB no. 0920-0307 exp.08 / 31 / 2016

Native Hawaiian/
Pacific Islander

Black

Asian

American Indian/
Alaskan Native

Ethnicity

Sex

Clinic

Patient Number

( SEE CODING INSTRUCTIONS ON BACK )

Year

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 40 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 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 73.60A Rev. 11-2013 (FRONT)

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

Coding Instructions
Specimens collected during:

Sentinel site codes

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.

Albuquerque

ALB

Atlanta

ATL

Birmingham

BHM

Boston

BOS

Buffalo

BUF

Chicago

CHI

Cleveland

CLE

Columbus

COL

Dallas

DAL

Greensboro

GRB

Honolulu

HON

Indianapolis

IND

Kansas City

KCY

Las Vegas

LVG

Los Angeles

LAX

Minneapolis

MIN

New Orleans

NOR

New York City

NYC

Orange County

ORA

Race (check all that apply):

Philadelphia

PHI

Phoenix

PHX

Pontiac

PON

Portland

POR

San Diego

SDG

San Francisco

SFO

Seattle

SEA

Tripler

TRP

American Indian or Alaska Native:
1=Yes
2=No
9=Unknown
Asian:
1=Yes
2=No
9=Unknown
Black or African-American:
1=Yes
2=No
9=Unknown
Native Hawaiian or other Pacific Islander:
1=Yes
2=No
9=Unknown
White:
1=Yes
2=No
9=Unknown
Other:
1=Yes
2=No
9=Unknown

Clinic:
For sentinel sites using more than one clinic, enter
the single digit assigned to the clinic from which the
gonococcal isolate was obtained.

Sex:
This variable refers to biological sex, rather than
gender. If the patient has male genitalia, please code
as male.
1=male
2=female
9=unknown

Ethnicity:
1=Hispanic or Latino
2=not Hispanic or Latino
9=unknown

Date of clinic visit (mm/dd/yyyy):
Enter month, day, and year of clinic visit at which
positive gonococcal culture was obtained. If day is
unknown, enter “01” for day.

Age:
Age in years. Code as “99” if unknown.

Sexual orientation:
Sex of the patient’s sexual partners within the past 3
months.
1=women only (heterosexual)
2=men only (homosexual)
3=women and men (bisexual)
9=unknown

CDC 73.60A Rev. 11-2013 (BACK)

Symptoms of urethral gonorrhea:
1=discharge and/or pain with urination (dysuria)
2=no discharge and no dysuria
9=unknown

Previous history of gonorrhea (ever):
Previous history of gonorrhea (lifetime); can be
obtained from medical record or by patient self-report.
1=Yes
2=No
9=Unknown

Non-Injection drug use (Non-IDU):
History of non-injection recreational drug use in
the previous 12 months. This excludes alcohol,
medications for erectile dysfunction, and steroids.
1=Yes
2=No
9=Unknown

Treatment 1:

Most current HIV status known at the time of clinic
visit for gonorrhea; obtained from medical record
or by patient self-report. Can include rapid tests for
which results are available on the day of the clinic visit.
1=positive
2=negative
3=indeterminate
9=unknown

Primary treatment for gonorrhea.
00=none
03=spectinomycin (Trobicin) 2 gm
04=ceftriaxone (Rocephin) 250 mg
05=ceftriaxone (Rocephin) 125 mg
06=ciprofloxacin (Cipro) 500 mg
07=cefoxitin (Mefoxin) 2 gm
12=cefixime (Suprax) 400 mg
14=cefpodoxime proxetil (Vantin) 200 mg
15=ofloxacin (Floxin) 400 mg
17=ceftizoxime (Cefizox) 500 mg
18=cefotaxime (Claforan) 500 mg
21=azithromycin (Zithromax) 2 gm
22=levofloxacin (Levaquin) 250 mg
23=cefpodoxime proxetil (Vantin) 400 mg
24=ceftibuten (Cedax) 400 mg
25=cefdinir (Omnicef ) 300 mg
26=cefdinir (Omnicef ) 600 mg
27= gemifloxacin 320 mg
28= gentamicin 240 mg (or weight-based
dosage)
88=other (please indicate in Other Treatment 1)
99=unknown

Travel history:

Other Treatment 1:

Number of previous gonorrhea episodes
(past 12 months):
Enter the number of previous episodes of gonorrhea
documented in the patient’s record within the past 12
months.
0=no documented previous episodes in the past
12 months (includes patients for whom this is the
initial clinic visit)
99=unknown (patient record not available or clinic
staff unable to collect this variable due to recordkeeping system)

HIV status:

Travel outside of the United States (50 U.S. States)
during the previous 60 days.
1=Yes
2=No
9=Unknown

If code “88” was entered for Treatment 1, please type
in the name and dosage of the drug used for primary
treatment of gonorrhea.

Sex work exposure:

Treatment 2:

History of giving or receiving drugs/money for sex in
the previous 12 months.
1=Yes
2=No
9=Unknown

Previous antibiotic use:
Any antibiotic use during the previous 60 days. This
should only include systemic antibiotics, taken orally
or by injection, and should not include antibiotic
ointments or eye drops.
1=Yes
2=No
9=Unknown

Injection drug use (IDU):
History of injection drug use in the previous 12
months.
1=Yes
2=No
9=Unknown

Second antimicrobial used as part of dual therapy
for gonorrhea treatment (and treatment of chlamydia,
if present)
00=none
01=ampicillin/amoxicillin
09=doxycycline (Vibramycin)/tetracycline
10=erythromycin
11=azithromycin (Zithromax) 1 gm
15=ofloxacin
21=azithromycin (Zithromax) 2 gm
22=levofloxacin
88=other
99=unknown

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