STD Clinic Data Elements

Form Approved

OMB No. 0920-NEW

Expiration Date: ##/## #/####

Public reporting burden of this collection of information is estimated to average 16 hours per response, including the time 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/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; Attn: OMB-PRA (0920-new)

Strengthening United States Response to Resistant Gonorrhea (SURRG)

Attachment 3A

SURRG Facility STD Clinic Data Elements

Variable name	Data element	Description/Question	Response codes
CL_PATIENTID	PatientID of case	Unique patient/person identification number This unique SURRG Patient ID will be assigned by the SURRG Epi Coordinator or other designee. It must be a unique per person, this patient ID cannot include any personally identifiable information (PII). SURRG grantees may elect to have this ID match the unique patient ID that is generated from their NEDDS Surveillance system, for GC-positive patients, or other unique patient ID Note: This Patient ID must be same as the Patient ID attached to SURRG isolates sent to the ARLN, and will be used to link all the clinical, laboratory, and epi investigation data as appropriate.	Character ID
CL_EVENTID	Event ID/case ID of case	Event identifier distinguishes each GC diagnosis or for GC-negative contacts, each clinic testing visit event. Regardless of how a jurisdiction comes up with the EVENTID, this ID must be unique for each case of GC or GC testing event, and should 1) stay the same for all associated clinic visits (i.e. testing, treatment, TOC), AND match with data in all other tables associated with this patient GC episode or GC testing event, including the LAB, CS, CT, PTSP tables. The ID can be up to 18 digits. This data element must not be ‘null’ or contain missing values.	Character ID
CL_STATE	State code	Identifies state of SURRG site (using digit state FIPS code)	06=California (CA) 08=Colorado (CO) 13=Georgia (GA) 15=Hawaii (HI) 18=Indiana (IN) 36=New York (NY) 37=North Carolina (NC) 53=Washington (WA) 55=Wisconsin (WI) 99=Unknown
VISDATE	Date of clinic visit		Character; YYYYMMDD
FACILITY_LOCATION	Facility location	Unique facility/clinic identifier This ID generated specifically for the SURRG activity and identifies the health center. A 3 character sentinel site code, hyphen, 2 digits (keep preceding 0 for single digits). Sites can notify SURRG Program to add additional facilities as needed.	Unique facility/clinic identifier This ID generated specifically for the SURRG activity and identifies the health center. A 3 character sentinel site code, hyphen, 2 digits (keep preceding 0 for single digits). ATL-01 Fulton County HD Aldredge Clinic (GA) ATL-02 Positive Impact (GA) ATL-03 AID Atlanta DEN-01 Denver Metro Health Clinic (CO) DEN-02 Denver Health Eastside Clinic (CO) DEN-03 Denver Health HIV/ID Clinic (CO) DEN-04 Not yet assigned DEN-05 Not yet assigned DEN-06 Not yet assigned DEN-07 Not yet assigned DEN-08 Not yet assigned GRB-01 Greensboro Clinic (NC) GRB-02 High Point Clinic (NC) GRB-03 Cone Health System Emergency Department GRB-04 Women’s Health (NC) GRB-05 Wesley Long Emergency Department (NC) GRB-06 Med Center High Point (NC) GRB-07 High Point Regional Emergency Department (NC) GRB-08 Not yet assigned GRB-09 Not yet assigned GRB-10 Not yet assigned HON-01 STD/HIV Clinic Diamond Head Health Clinic (HI) HON-02 Not yet assigned HON-03 Not yet assigned HON-04 Not yet assigned HON-05 Not yet assigned HON-06 Not yet assigned IND-01 Bell Flower Clinic (IN) IND-02 Community Hospital East Emergency Department (IN) IND-03 Community Hospital East Infectious Disease Clinic (IN) IND-04 Damien Center (IN) IND-05 Eskenazi Hospital (IN) IND-06 Not yet assigned IND-07 Not yet assigned IND-08 Not yet assigned IND-09 Not yet assigned MIL-01 Keenan Health Center STD Clinic (WI) MIL-02 Brady East STD Clinic/BEST (WI) MIL-03 WI Ave Planned Parenthood Clinic (WI) MIL-04 Northwest Planned Parenthood Clinic (WI) MIL-05 Not yet assigned MIL-06 Not yet assigned MIL-07 Not yet assigned NYC-01 Fort Greene STD Clinic (NYC) NYC-02 Riverside STD Clinic (NYC) NYC-03 Callen-Lorde Community Health Center (NYC) NYC-04 APICHA Community Health Center (NYC) NYC-05 Gotham Medical Group (NYC) NYC-06 Not yet assigned NYC-07 Not yet assigned NYC-08 Not yet assigned NYC-09 Not yet assigned NYC-10 Not yet assigned NYC-11 Not yet assigned NYC-12 Not yet assigned NYC-13 Not yet assigned NYC-14 Not yet assigned NYC-15 Not yet assigned SEA-01 Public Health - Seattle & King County (PHSKC) STD Clinic (WA) SEA-02 Madison Clinic at Harborview Medical Center HIV (WA) SEA-03 Peter Shalit MD and Associates (WA) SEA-04 Seattle Infectious Disease Clinic (WA) SEA-05 Capitol Hill Medical (WA) SEA-06 Planned Parenthood-Kent (WA) SEA-07 Planned Parenthood-Federal Way (WA) SEA-08 Not yet assigned SEA-09 Not yet assigned SEA-10 Not yet assigned SFO-01 San Francisco City Clinic (SF/CA) SFO-02 3rd Street Youth Center (SF/CA) SFO-03 Not yet assigned SFO-04 Not yet assigned SFO-05 Not yet assigned OPR-00 Other Non-SURRG) Provider Grantees should notify CDC SURRG Program when new facilities are assigned.
COUNTYRES	County of patient’s residence	3-digit FIPS county code (Use 999 if unknown)	Character
PTXCTRACT	Census tract of patient’s residence	11 digit census tract code (2 digit state-3 digit county-6 specific census tract)	Character
PTJURIS	Does patient reside in funded jurisdiction	Does the patient reside in the funded jurisdiction (typically the county funded for SURRG; CA – SURRG region; NYC – NYC)	0=No 1=Yes 9=Unknown
GENDER	Patient’s gender	How do you describe your gender identity?	1=Male 2=Female 3=Female-to-male transgender (FTM) 4=Male-to-female transgender (MTF) 5=Other gender identity 8=Refused to Answer 9=Unknown
SEXBIRTH	Sex on birth certificate	What sex were you assigned at birth, on your original birth certificate?	1=Male 2=Female 8=Refused to Answer 9=Unknown
PT_AGE	Patient age	How old is the patient? [Calculated as visitdate-birthdate; do not round up]	Numeric; 999=Unknown
HISP_ETH	Ethnicity: Hispanic or Latino	Is the patient of Hispanic ethnicity?	0=No 1=Yes 8=Refused to Answer 9=Unknown
AIAN	Race: AI/AN-American Indian or Alaskan Native	Does the patient identify as American Indian or Alaska Native?	0=No 1=Yes 8=Refused to Answer 9=Unknown
ASIAN	Race: Asian	Does the patient identify as Asian?	0=No 1=Yes 8=Refused to Answer 9=Unknown
NHOPI	Race: NH/PI-Native Hawaiian or Other Pacific Islander	Does the patient identify as Native Hawaiian or Pacific Islander?	0=No 1=Yes 8=Refused to Answer 9=Unknown
BLACK	Race: Black or African American	Does the patient identify as black or African-American?	0=No 1=Yes 8=Refused to Answer 9=Unknown
WHITE	Race: White	Does the patient identify as white?	0=No 1=Yes 8=Refused to Answer 9=Unknown
MULTIRACE	Race: Multirace	Does the patient identify as multiracial?	0=No 1=Yes 8=Refused to Answer 9=Unknown
OTHRACE	Race: Other	Does the patient identify as another race not listed?	0=No 1=Yes 8=Refused to Answer 9=Unknown
PREGNANT	Pregnancy status at clinic visit	Is the patient pregnant today? Optional [Use response 7 if patient is male or MTF; use response 9 if didn’t assess on female patient]	0=No 1=Yes 7=Not Applicable 8=Refused to Answer 9=Unknown
GISP_GCHX	Previous self-reported history of gonorrhea (ever)		0=No 1=Yes 8=Refused to Answer 9=Unknown
SURV_GCHX	Previous documented history of gonorrhea (ever)		0=No 1=Yes 9=Unknown
GISP_GCHXN	Previous episodes of gonorrhea	Number of previous documented episodes of gonorrhea (past 12 months)	Numeric 99=number is unknown, missing, or not captured
GISP_ANTIBIOT	Antibiotic use	Has patient used any antibiotics during the previous 2 months?	0=No 1=Yes 8=Refused to Answer 9=Unknown
ANTIBIOT_NAME	Name of antibiotic used	If patient reported using antibiotics during the previous 2 months, which antibiotic(s) was used? Optional	00=none 01=ampicillin/amoxicillin (Augmentin) 04=ceftriaxone (Rocephin) 06=ciprofloxacin (Cipro) 09=doxycycline (Vibramycin)/tetracycline 10=erythromycin 11=azithromycin (Zithromax, Zpack) 12=cefixime (Suprax) 22=levofloxacin (Levaquin) 23=cefpodoxime proxetil (Vantin) 31=penicillin 77=other 99=unknown
GISP_SEXWRK	History of sex work	Does patient have a history of giving or receiving drugs/money for sex in the previous 12 months?	0=No 1=Yes 8=Refused to Answer 9=Unknown
GISP_IDU	History of injection drug use	Does patient have a history of injection drug use in the previous 12 months?	0=No 1=Yes 8=Refused to Answer 9=Unknown
GISP_NONIDU	History of non-injection recreational drug use	Does patient have a history of non-injection recreational drug use in the previous 12 months (excludes alcohol, medications for erectile dysfunction, and steroids)?	0=No 1=Yes 8=Refused to Answer 9=Unknown
GISP_ETRVL	Case travel status and sex activity	Has the patient traveled outside of US in the past 2 months, and had condomless oral, anal, or vaginal sex with someone other than a traveling companion? [Optional if non-GISP or not contained in EMR]	0=No 1=Yes 8=Refused to Answer 9=Unknown
GISP_ETRVL2	Partner travel status and sex activity	In the past two months, has the patient had condomless oral, anal, or vaginal sex with someone who recently traveled to or from another country? [Optional if non-GISP or not contained in EMR]	0=No 1=Yes 8=Refused to Answer 9=Unknown
PENALLERGY	Penicillin allergy	Does patient report a penicillin allergy?	0=No 1=Yes 8=Refused to Answer 9=Unknown
MENSEX	Number of male sex partners	How many MEN did the patient have sex with in the previous 2 or 3 months?	Numeric (Note: If number is unknown, missing or not captured, use null value). 999=number is unknown, missing, or not captured
MEN_TIME	Time interval used to capture patient’s number of male sex partners	What interview period was used to obtain the patient’s number of male sex partners?	1=2 months 2=3 months 9=Unknown/Not Applicable
FEMSEX	Number of female sex partners	How many WOMEN did the patient have sex with in the previous 2 or 3 months?	Numeric (Note: If number is unknown, missing or not captured, use null value). 999=number is unknown, missing, or not captured
FEM_TIME	Time interval used to capture patient’s number of female sex partners	What interview period was used to obtain the patient’s number of female sex partners?	1=2 months 2=3 months 9=Unknown/Not Applicable
GENDER_SP	Gender of sex partners	Provider documented gender of patient’s sex partners	1=Males only 2=Females only 3=Both Males and Females 9=Unknown
ExpSTD_PTR	Partner notification of gonorrhea exposure	Before you came to the clinic today, did any of your sex partners tell you that you might have recently been exposed to gonorrhea?	0=No 1=Yes 8=Refused to Answer 9=Unknown
ExpSTD_HD	Health department notification of gonorrhea exposure	Before you came to the clinic today, did the health department/DIS tell you that you might have had sex with someone with gonorrhea (or an STD)?	0=No 1=Yes 8=Refused to Answer 9=Unknown
SXPHARYNGEAL	Reported pharyngeal/throat pain	Does the patient report pharyngeal/throat pain?	0=No 1=Yes 8=Refused to Answer 9=Unknown
SXDYSURIA	Reported dysuria	Does the patient report dysuria?	0=No 1=Yes 8=Refused to Answer 9=Unknown
SXDISCHARGE	Reported genital discharge	Does the patient report genital discharge?	0=No 1=Yes 8=Refused to Answer 9=Unknown
SXRECTAL	Reported rectal symptoms	Does the patient report rectal symptoms (e.g. pain or tenesmus)?	0=No 1=Yes 8=Refused to Answer 9=Unknown
SXABDOMEN	Reported abdominal pain	Does the patient report abdominal pain?	0=No 1=Yes 8=Refused to Answer 9=Unknown
EVERHIV	Prior HIV testing self-reported	Has the patient ever been tested for HIV (prior to today)?	0=No 1=Yes 8=Refused to Answer 9=Unknown
WHENHIVM	Last HIV test self-reported	When was the patient’s last HIV test? Leave Blank if EverHIV=0, 8, or 9	MM (month reported); 99=Unknown
WHENHIVY	Last HIV test self-reported	When was the patient’s last HIV test? Leave Blank if EverHIV=0, 8, or 9	YYYY (year reported); 9999=Unknown
HIVRESULTLAST	HIV result self-reported	What was the result of that patient’s HIV test (excluding testing on today’s visit)?	0=Negative 1=Positive 2=Indeterminate 7=Never tested 8=Refused to Answer 9=Unknown
GISP_HIVRESULT	HIV result self-reported at clinic visit	If tested at this visit, what was the result of this patient’s HIV test?	0=Negative 1=Positive 2=Indeterminate 7=Not tested today 8=Refused to Answer 9=Unknown
PREP	PrEP use	Is the patient currently using HIV pre-exposure prophylaxis (PrEP)? [Response=7 if HIV-positive]	0=No 1=Yes 7=Not applicable 8=Refused to Answer 9=Unknown
PREP_REFER	PrEP referral	If not on PrEP, was the patient offered or referred for PrEP (on day of visit)? [Response=7 if HIV-positive or already on PrEP]	1=Yes referred 2=Not referred, but eligible for referral 3=Not referred, due to ineligibility 7=Not applicable 9=Unknown
HIVCARE	HIV care	Is the patient currently receiving HIV medical care (in the past 12 months)? [Response=7 if HIV-negative or never HIV tested]	0=No 1=Yes 7=Not applicable 8=Refused to Answer 9=Unknown
HIVCARE_REFER	HIV care referral	If not currently receiving HIV medical care, was patient referred to care? [Response=7 if HIV-negative or never tested]	0=No 1=Yes 7=Not applicable 9=Unknown
DATETX	Date of Gonorrhea treatment	Date patient received gonorrhea treatment	Character; YYYYMMDD
TRMT1	Primary Gonorrhea treatment	What is the patient’s primary treatment for gonorrhea? [Choose 00=none, i.e. not treated 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) 77=other (please indicate in other medication prescribed) 99=unknown
MEDICATION1_OTH	Other medication prescribed	If the patient received a medication other than what is listed above (and Medication 1 was coded as 77 for ‘other’), please provide the name of the other medication. Leave blank if not applicable	Free text field
TRMT2	Secondary Gonorrhea treatment	What second antimicrobial used as part of dual therapy for gonorrhea treatment (and treatment of chlamydia, if present)? [Choose 00=none, i.e. not treated for gonorrhea, or use response 00 if no 2nd antimicrobial was used for treatment]	00=none 01=ampicillin/amoxicillin 09=doxycycline (Vibramycin) 100mg bid x 7 days 11=azithromycin (Zithromax) 1 gm 21=azithromycin (Zithromax) 2 gm 77=other 99=unknown
TOC_VIS	Test of cure visit identification	Was this a test of cure visit or was this patient recently treated for gonorrhea at this clinic (or a partnering clinic) within the past 4 weeks?	0=No (stop) 1=Yes (potential treatment failure or persistent infection; proceed to next question)
TCT_SEX	Sexual activity	Has patient engaged in any sexual activity with a new sex partner since recent GC treatment? (If yes, proceed to condomless sexual activity question. If no, proceed to sexual activity with same partner question)	0= No (potential treatment failure) 1=Yes (potential new infection) 8=Refused to Answer 9=Unknown
TCT_CONDUSE	Condomless sexual activity	Did patient use condoms or barrier method every time they’ve had sex with this new sex partner	0= No (potential treatment failure) 1=Yes (potential new infection) 8=Refused to Answer 9=Unknown
TCT_SAMEPTR	Sexual activity with same partner	Since recent GC treatment, has patient engaged in any sexual activity with someone they also had sex with in the 2 months prior to recent treatment? (If yes, proceed to condomless sexual activity with same partner question)	0= No (potential treatment failure) 1=Yes 8=Refused to Answer 9=Unknown
TCT_SAMPETRCU	Condomless sexual activity with same partner	Since recent GC treatment, did patient use condoms or barrier method every time they had sex with this/these on-going sex partners?	0=No (new infection) 1=Yes (potential treatment failure) 8=Refused to Answer 9=Unknown

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