Non-STD Clinic Data Elements

Form Approved

OMB No. 0920-NEW

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

Public reporting burden of this collection of information is estimated to average 3 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 3B

SURRG Facility non-STD Clinic Data Elements

Data element	Description and Response Codes
CL_PATIENTID	SURRG record IDs from interviews will created and assigned (by the local or state health department) a unique patient identifier (patient ID). CDC will only receive the unique identifier and will not have the ability to back-convert the Patient ID or other event ID to a medical record number, name, social security number, or date of birth. (see SSA 9)
CL_EVENTID	This ID up to 18 characters in length. SURRG records from interviews will be assigned (by the local or state health department) a unique event identification number for each investigation. CDC will only receive the unique identifier and will not have the ability to back-convert the Patient ID or other event ID to a medical record number, name, social security number, or date of birth.
CL_STATE	SURRG Project State code (using state FIPS code) This 2 character code identifies the state 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 (e.g. date of specimen collection) YYYYMMDD This data element must not be ‘null’ or contain missing values
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). 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 Character (Use 999 if unknown)
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 the patient reside in the funded jurisdiction (typically the county funded for SURRG; CA – SURRG region; NYC – NYC) 0=No 1=Yes 9=Unknown (Use 9 if not collected)
GENDER (If non-STD sites can only capture sex, capture sex as 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	What sex were you assigned at birth, on your original birth certificate? 1=Male 2=Female 8=Refused to Answer 9=Unknown
PT_AGE	How old is the patient? (Age in years) Numeric If age is unknown or missing, use 99. [Calculated as visitdate-birthdate; do not round up]
HISP_ETH	Is the patient of Hispanic ethnicity? 0=No 1=Yes 8=Refused to Answer 9=Unknown
AIAN	Does the patient identify as American Indian or Alaska Native? 0=No 1=Yes 8=Refused to Answer 9=Unknown
ASIAN	Does the patient identify as Asian? 0=No 1=Yes 8=Refused to Answer 9=Unknown
NHOPI	Does the patient identify as Native Hawaiian or Pacific Islander? 0=No 1=Yes 8=Refused to Answer 9=Unknown
BLACK	Does the patient identify as black or African-American? 0=No 1=Yes 8=Refused to Answer 9=Unknown
WHITE	Does the patient identify as white? 0=No 1=Yes 8=Refused to Answer 9=Unknown
MULTIRACE	Does the patient identify as multiracial? 0=No 1=Yes 8=Refused to Answer 9=Unknown
OTHRACE	Does the patient identify as another race not listed? 0=No 1=Yes 8=Refused to Answer 9=Unknown
GENDER_SP	Provider-documented gender of patient’s sex partners? 1=Males only 2=Females only 3=Both Males and Females 9=Unknown
DATETX	Date of gonorrhea (GC) treatment YYYYMMDD
TRMT1	What is the patient’s 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) 77=other (please indicate in Other Treatment 1) 99=unknown [Choose 00=none, i.e. not treated for gonorrhea.]
MEDICATION1_OTH	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. Free text description of the other medication Leave blank if not applicable
TRMT2	What 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) 100mg bid x 7days 11=azithromycin (Zithromax) 1 gm 21=azithromycin (Zithromax) 2 gm 77=other 99=unknown [Choose 00=none, i.e. not treated for gonorrhea, or use response 00 if no 2nd antimicrobial was used for treatment]

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