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pdfForm Approved
OMB No. 0920-1072
Expiration Date ##/##/20##
SSuN Protocol (V10.0)
Attachment 5
Data Elements Listing
Enhanced STD Surveillance Network (SSuN)
OMB# 0920-1072
Public reporting burden of this collection of facility component information is estimated to average 3 hours per response; these
data elements were developed collaboratively and agreed upon by members of eSSuN and do not include information beyond what
is routinely collected from patients during the clinical visit. 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 D-74, Atlanta, GA 30333, ATTN: PRA (0920-1072). Do not send the completed
form to this address.
Form Approved
OMB No. 0920-1072
Expiration Date ##/##/20##
SSuN Protocol (V10.0)
Number
1
Change
Variable Name
P1_SiteID
Description/Coding
SSuN Site ID
This 2 character code primarily identifies sites funded under SSuN Cycle 3 and
may include additional sites as required throughout the grant period. This data
element MUST NOT be ‘null’ or contain missing values.
BA=Baltimore
CA=California
FL=Florida
MA=Massachusetts
MN=Minnesota
MC=Multnomah County
NY=New York City
PH=Philadelphia
SF=San Francisco
WA=Washington
Supplemental codes – for historical data only:
VA=Virginia (Cycle II)
AL=Alabama (Cycle II)
CO=Colorado (Cycle II)
CH=Chicago (Cycle II)
This data element MUST NOT be ‘null’ or contain missing values.
2
P1_EventID
Site generated unique event identifier
This record ID should be supplied by the site and may be an event or report
identifier from underlying surveillance system. Regardless of source, this ID
must be unique for each confirmed case report. This data element MUST NOT
be ‘null’ or contain missing values.
3
P1_PatientID
Site generated ID allows for longitudinal tracking of unique persons
This ID should be supplied by the site and may be a unique patient identifier
from underlying surveillance systems or may be generated specifically for SSuN
from identifying information provided through case reporting. Regardless of
source, this ID must be unique and allow for longitudinal tracking of persons
reported with multiple episodes of disease. This data element MUST NOT be
‘null’ or contain missing values.
4
P1_RecRepDte
Earliest date this specific disease event/report received at health department?
This date should reflect the earliest information available to the health
department regarding the case. This date should include laboratory records
received if lab results were reported prior to receipt of a provider case report.
This data element MUST NOT be ‘null’ or contain missing values. This should be
coded as a ‘SAS’ numeric date.
5
P1_RandSamp
Is this record/case selected in the random sample?
This data element MUST NOT be ‘null’ or contain missing values.
0=Not in random sample
1=In random sample
6
P1_SampDte
Date record/case sampled by jurisdiction
For jurisdiction deploying a batch process for record sampling, this should be
the actual date that the batch was sampled. For jurisdictions deploying realtime sampling of cases through their surveillance system, this date should
match the report date (or date case status was confirmed if appropriate). This
data element should not be ‘null’ or contain missing values. This should be
coded as a ‘SAS’ numeric date.
7
P1_RecSx
Was lab or provider report how case was initially reported to the health
department?
This data element is intended to capture the source of the initial case
notification to the health department. If the grantee is not able to reliably
capture this information for a specific case, this must be documented by
entering a value of ‘3’ for that case record. This data element should not be
‘null’ or contain missing values.
0=Laboratory report, electronic
1=Laboratory report, paper
2=Provider report, electronic or paper
3=Report source not captured by surveillance system
Form Approved
OMB No. 0920-1072
Expiration Date ##/##/20##
SSuN Protocol (V10.0)
8
P1_PrevPtx
Is patient previously known to HD from infectious disease reporting records
(TB, HIV, STDs, Hep)?
This data element is designed to capture whether this patient is known to the
HD from a previous case report. This data element should not be ‘null’ or
contain missing values. If a match with previous patients is not done, please
code as a new patient. If a subsequent match is performed and patient found
to be previously reported, the value should be changed accordingly.
0=New Patient, not previously reported
1=Patient previously reported
9
P1_InitSx
If patient previously reported, what is the registry/source of earliest report for
this PATIENT?
0=STD Registry
1=HIV Registry
2=Viral Hepatitis Registry
3=Other Disease Registry
4=Unknown
10
P1_HregMatch
Was eHARS registry match done for this patient?
This data element may be initially coded as ‘2’ if the grantee conducts a batch
match with their HIV registry and the case is reported before that batch is
processed. This information can be updated in the SSuN record in the next data
transmission following the match. This data element should not be ‘null’ or
contain missing values.
1=Yes
2=No
11
P1_HregMatchStat
Did this patient match a registry entry in eHARS?
This data element may be initially coded as ‘3’ if the grantee conducts a batch
match with their HIV registry and the case is reported before that batch is
processed. This information can be updated in the SSuN record in the next data
transmission following the match. This data element should not be ‘null’ or
contain missing values.
1=Matching Record Found
2=No Matching Record
3=Match Not Performed
12
P1_HDXMOYR
What is this patient's earliest indication of HIV positive result?
This information can be obtained from the eHARS person table (HIVPMOYR). If
eHARS match found. This should be coded as character data (“MM/YY”) with
missing information as “../..” or “../YY”
13
P1_Othno
Additional registry number
If this patient also has a record in other/ancillary disease registries. This is
primarily for local use in matching patient records to update missing
information.
14
P1_Othsx
Additional registry source
If this patient also has a record in other/ancillary disease registries and
P1_Othno is not blank, this element should be populated with the source.
0=STD Registry
1=HIV Registry
2=Viral Hepatitis Registry
3=Other Disease Registry
4=Unknown
15
P1_PrevDx
Most recent previous diagnosis (if applicable; could include hep, TB or HIV)
If this patient also has a record in other/ancillary disease registries as indicated
by #13 & 14 above, indicate the diagnosis documented by that record? Should
be ‘Null’ if no previous diagnosis is confirmed.
10311=Syphilis, primary
10312=Syphilis, secondary
10313=Syphilis, early latent
10315=Syphilis, unknown latent
10314=Syphilis, late latent
10318=Syphilis, late with symptoms
10280=Gonorrhea
Form Approved
OMB No. 0920-1072
Expiration Date ##/##/20##
SSuN Protocol (V10.0)
10274=Chlamydia
10100=Hepatitis B, acute
10105=Hepatitis B, chronic
20001=Hepatitis C
10562=HIV infection (non-AIDS)
10560=AIDS
10307=Nongonococcal Urethritis (NGU)
10308=Muco-purulent cervicitis (MPC)
10309=Pelvic Inflammatory Disease (PID)
10273=Chancroid
10306=Lymphogranuloma venereum (LGV)
10276=Granuloma Inguinale
20002=TB
20003=Other
16
P1_PrevDxDte
Date of most recent previous diagnosis documented above.
Should not be null if P1_PrevDx is not null.
16.1
P1_PrevGCDx
Has the patient been previously diagnosed and reported with GC?
1=Yes
2=No
3=Registry records not searched
16.2
P1_PrevGCDxDte
Date of most recent previous diagnosis of GC documented above.
Should not be null if P1_PrevGCDx = 1. This should be coded as a ‘SAS’ numeric
date.
17
P1_CaseDup
Is this record/case a duplicate report, new report or was duplicate status not
determined?
The grantee should document if an initial case report was subsequently found
to be a duplicate of an existing case – the record should be retained in the SSuN
dataset and coded as a duplicate (‘1’)? If the jurisdiction receives a report that
they know to be a duplicate at the time of report, the record can be omitted
from the SSuN datasets and not sampled for enhanced investigation. This data
element should not be ‘null’ or contain missing values.
0=New Case
1=Duplicate Case (previously reported <15 days)
9=Unknown, site surveillance system does not capture
18
P1_FacilityID
Site generated facility ID. Each reporting provider/facility must have a
This is a primary key for linking the provider type and other provider
information to the case record. Historically, the majority of cases in any
grantee’s jurisdictions will be reported from known providers, but for cases
reported from entirely new or unknown providers, this field should be
populated with that facility’s new number and be included in the next update
of the provider reference file. This data element should not be ‘null’ or contain
missing values.
19
P1_Dispo
What is the status of the internal health department (Phase 1)
The investigation referred to for this data element includes the search of
existing health department records, matching and merging with electronic or
other laboratory data, eHARS match and other disease registries. At initial
report, cases may be coded as ‘10’. This should be updated as appropriate.
Cases listed as pending should be updated within 60 days and this information
updated in the next SSuN data transmission. This data element should not be
‘null’ or contain missing values. Jurisdictions may choose to initiate phase 1
investigations on all reported cases, regardless of whether they fall into the
random sample, or may elect to initiate phase 1 investigations on only those
records in the random sample.
0=Investigation complete: record referred to phase 2
1=Investigation complete: no further action, record determined
2=Investigation complete: no further action, case determined to
3=Investigation complete: no further action, case not in SSuN
4=Investigation complete: no further action, case not eligible for
10=Investigation not complete: P1 investigation pending
11=Investigation not complete: no further action, insufficient
22=Investigation not complete: record not in random sample
Form Approved
OMB No. 0920-1072
Expiration Date ##/##/20##
SSuN Protocol (V10.0)
20
P1_Referral1
Is this record/case referred for provider (Phase 2) investigation?
This indicates whether the record has been referred to provider investigation
(methods of which will differ across SSuN sites). If provider is not contacted,
surveyed or otherwise followed up with to supply any additional case-specific
information, code as ‘1’. This data element should not be ‘null’ or contain
missing values.
0=Referred to P2 Investigation
1=Not Referred to P2 Investigation
2=Referral Pending
21
P1_PtxSex
Sex of the patient as indicated on initial health department report?
This data element should not be ‘null’ or contain missing values.
1=Male
2=Female
3=Male-to-Female TG
4=Female-to-Male TG
5=TG Unknown or Unspecified
9=Unknown
22
P1_PtxRace_White
White Race
Information from case/lab reports to the health department only. Patient selfreport from interviews should be captured in #110 – 116. If additional
information from any source (other than patient report) is received, #22
through 27 may be updated as required by underlying surveillance system.
1=Yes
2=No
3=Unknown
4=Refused
23
P1_PtxRace_Black
Black Race
Information from case/lab reports to the health department only. Patient selfreport from interviews should be captured in #110 – 116. If additional
information from any source (other than patient report) is received, #22
through 27 may be updated as required by underlying surveillance system.
1=Yes
2=No
3=Unknown
4=Refused
24
P1_PtxRace_AIAN
American Indian/Alaska Native Race
Information from case/lab reports to the health department only. Patient selfreport from interviews should be captured in #110 – 116. If additional
information from any source (other than patient report) is received, #22
through 27 may be updated as required by underlying surveillance system.
1=Yes
2=No
3=Unknown
4=Refused
25
P1_PtxRace_Asian
Asian Race
Information from case/lab reports to the health department only. Patient selfreport from interviews should be captured in #110 – 116. If additional
information from any source (other than patient report) is received, #22
through 27 may be updated as required by underlying surveillance system.
1=Yes
2=No
3=Unknown
4=Refused
26
P1_PtxRace_NHOPI
Native Hawaiian/Other Pacific Islander Race
Information from case/lab reports to the health department only. Patient selfreport from interviews should be captured in #110 – 116. If additional
information from any source (other than patient report) is received, #22
through 27 may be updated as required by underlying surveillance system.
1=Yes
Form Approved
OMB No. 0920-1072
Expiration Date ##/##/20##
SSuN Protocol (V10.0)
2=No
3=Unknown
4=Refused
27
P1_PtxRace_Other
Other Race
Information from case/lab reports to the health department only. Patient selfreport from interviews should be captured in #110 – 116. If additional
information from any source (other than patient report) is received, #22
through 27 may be updated as required by underlying surveillance system.
1=Yes
2=No
3=Unknown
4=Refused
28
P1_PtxRace_UNK
Is all information on race and Hispanic ethnicity missing from initial
If additional/supplemental information is received on race and ethnicity of
patient but this information was missing from the initial report to the health
department, please leave this data element coded as ‘1’ and capture the source
of supplemental information in #29 below.
1=Yes
2=No
29
P1_PtxRaceSource
What is the source of the final race information of record as ascertained for this
patient?
For grantees able to distinguish the source of information for race, please
indicate as appropriate. For grantees NOT able to distinguish the source of race
data at all, code as ‘6’. If race information is missing/unknown from all sources,
code as ‘5’.
1=Patient Self-Report
2=Provider Case Report
3=Laboratory Report
4=Previous Registry Record
5=No Information Available from Any Source
6=Source not Identifiable
30
P1_PtxHisp
Patient Hispanic ethnicity
Information from case/lab reports to the health department only. Patient selfreport from interviews should be captured in #109. If additional information
from any source (other than patient report) is received, #30 may be updated as
required by underlying surveillance system.
1=Hispanic
2=Non-Hispanic
3=Unknown
4=Refused
31
P1_PtxHISPSource
What is the source of the final Hispanic ethnicity information
For grantees able to distinguish the source of information for Hispanic
ethnicity, please indicate as appropriate. For grantees NOT able to distinguish
the source of Hispanic ethnicity data at all, code as ‘6’. If information is
missing/unknown from all sources, code as ‘5’.
1=Patient Self-Report
2=Provider Case Report
3=Laboratory Report
4=Previous Registry Record
5=No Information Available from Any Source
6=Source not Identifiable
32
P1_PtxAGE
Age of patient from initial reporting record/document .
If age information is missing/unknown from all sources, use null value.
33
P1_PtxAgeUnit
Age unit
If #32 is null, use null value for this data element (‘.’)
1=Years
2=Months
34
P1_PtxCountyres
County of patient residence
Form Approved
OMB No. 0920-1072
Expiration Date ##/##/20##
SSuN Protocol (V10.0)
If information is missing/unknown, code to null value ( ‘.’)
35
P1_PtxCTract
Census Tract of patient residence
If information is missing/unknown, code to null value (‘.’)
36
P1_PtxAddrStat
Was patient street address present and complete in initial reporting
documents?
This data element should not be ‘null’ or contain missing values.
1=Street Address Known
2=Street Address Missing
3=Street Address Incomplete
37
P1_GCAccuracy
What is the basis of census tract assignment (XY coordinates, street
This data element should not be ‘null’ or contain missing values.
1=Close (based on direct street segment, parcel, or l
2=Approximate (modification of address required to match to
3=Very approximate (based only on zip or city centroid)
4=Not-geocodable (insufficient data to geocode, PO Box,
5=Data suppressed by Site policy
9=Missing (no address available)
38
P1_DxDte
What is the diagnosis date for the current episode of disease (may be date of
provider visit, specimen collection date, laboratory report date or other
suitable proxy)
This data element should not be ‘null’ or contain missing values. This should be
coded as a ‘SAS’ numeric date.
39
P1_DxCode
Diagnosis (for gonorrhea cases, this value = 10280)
This data element should not be ‘null’ or contain missing values.
10280=Gonorrhea
40
P1_SiteUrine
Urine 'site' of infection, usually a proxy for urethral infection in men but
If information is missing/unknown, code as ‘3’
1=Yes
2=No
3=Unknown
41
P1_SiteVagCerv
Vaginal or cervical site of infection in women - combined because there
If information is missing/unknown, code as ‘3’
1=Yes
2=No
3=Unknown
42
P1_SiteUreth
Urethral site of infection - only if this is specifically indicated, if the only
If information is missing/unknown, code as ‘3’
1=Yes
2=No
3=Unknown
43
P1_SiteRect
Rectal site of infection
If information is missing/unknown, code as ‘3’
1=Yes
2=No
3=Unknown
44
P1_SitePhar
Pharyngeal site of infection
If information is missing/unknown, code as ‘3’
1=Yes
2=No
3=Unknown
45
P1_SiteEye
Ocular site of infection
If information is missing/unknown, code as ‘3’
Form Approved
OMB No. 0920-1072
Expiration Date ##/##/20##
SSuN Protocol (V10.0)
1=Yes
2=No
3=Unknown
46
P1_SiteSera
Blood or sera infection
If information is missing/unknown, code as ‘3’
1=Yes
2=No
3=Unknown
47
P1_SiteJoint
Joint or synovial fluid infection
If information is missing/unknown, code as ‘3’
1=Yes
2=No
3=Unknown
48
P1_SiteOTH
Site of infection, not specified above
If information is missing/unknown, code as ‘3’
1=Yes
2=No
3=Unknown
49
P1_SiteUNK
All site of infection information missing for this case - use only if no other
information is available.
If the answer to any one of 40-48 above is ‘1’ or ‘2’ then this data element
should be coded ‘2’. If all data elements 40-48 are coded as ‘3’ then code this
data element as ‘1’.
1=Yes
2=No
Population Component – Phase 1 – Laboratory Records
50
P1_L1_EventID
Unique identifier for associated surveillance record
Will be a primary key for merging lab and case data; should correspond to
P1_EventID. This data element MUST NOT be ‘null’ or contain missing values.
51
P1_L1_LabID
Unique identifier for laboratory performing testing
Site assigned; may be ID from other system or specifically created for SSuN. If
performing lab is not known, site should still create a lab record with a locally
defined ID corresponding to unknown lab that they will use throughout the
SSuN data collection period. This data element should not be ‘null’ or contain
missing values.
52
P1_L1_Accession
Unique identifier (accession number) for laboratory record
Leave blank (null) if not available/ascertained
53
P1_L1_PatientID
Unique identifier for person (allowing longitudinal tracking of persons)
Will be a secondary key for merging lab and case data; should correspond to
P1_PatientID. This data element MUST NOT be ‘null’ or contain missing values.
54
P1_L1_CondTested
specific condition/pathogen tested
This data element MUST NOT be ‘null’ or contain missing values.
1=Syphilis
2=Gonorrhea
3=Chlamydia
4=Genital Herpes
5=Trichomoniasis
6=HIV
7=Hep A
8=Hep B
9=Hep C
10=BV
11=Other
55
P1_L1_SpecColDte
Specimen collection date - this is often used as a proxy for diagnosis
Form Approved
OMB No. 0920-1072
Expiration Date ##/##/20##
SSuN Protocol (V10.0)
This data element should not be ‘null’ or contain missing values. This should be
coded as a ‘SAS’ numeric date.
56
P1_L1_LabRepDte
This is the date that the performing lab reported the results to the
This should be coded as a ‘SAS’ numeric date.
57
P1_L1_SecType
Type of specimen
This data element should not be ‘null’ or contain missing values.
1=Exudate
2=Blood/sera
3=Synovial fluid
4=Urine
5=CSF
6=Tissue
7=Saliva
8=Other
9=Unknown
58
P1_L1_AnatSite
This is the anatomic site from which the specimen was obtained and is
important in determining the anatomic site of infection.
This data element should not be ‘null’ or contain missing values.
1=Urethra
2=Vagina/cervix
3=Urine
4=Rectum
5=Pharynx
6=Eye
7=Sera/Blood
8=Joint
9=Other Anatomic Site
10=Unknown Anatomic Site
59
P1_L1_TestType
As test technology advances, it is important to obtain the type of test
performed
This data element should not be ‘null’ or contain missing values.
1=Culture,
2=NAAT
3=Non-amplified nucleic acid test/DNA probe
4=Gram Stain
5=DFA
6=Rapid HIV
7=ELISA
8=Western blot
9=Pooled RNA
10=RPR
11=VDRL
12=FTA
13=TP-PA
14=MHA
15=Wet Mount/Clue Cell
16=PH
17=Other
18=Unknown
60
P1_L1_QualRes
Qualitative result: For most pathogens/tests, positive, negative,
This data element should not be ‘null’ or contain missing values.
1=Positive
2=Negative
3=Reactive
4=Weakly Reactive
5=Non-Reactive
6=Equivocal/Indeterminate
7=Specimen Inadequate/Contaminated
8=Other
9=Unknown
61
P1_L1_Quantres
Not currently relevant to GC/CT but may become relevant in the future.
Form Approved
OMB No. 0920-1072
Expiration Date ##/##/20##
SSuN Protocol (V10.0)
Population Component – Phase 2 – Provider Investigation
62
P2_ProvID
Unique facility/provider ID
This data element MUST NOT be ‘null’ or contain missing values for cases in the
random sample. SHOULD NOT be null for all other cases (collaborators
requested to include this information for all gonorrhea case records – this can
be accomplished with a default coding of P2_ProvID= P1_FacilityID.
63
P2_ProvCO
County FIPS code for provider/facility physical location
This should be coded as the 3-digit FIPS code for the county.
64
P2_ProvZIP
Facility/provider physical location 5-digit ZIP
65
P2_ProvCHC
Is facility/provider a Community Health Center (CHC)?
Community Health Centers are not-for-profit primary care organizations
governed by a community board and whose primary mission is to provide
medical services to traditionally under-served populations. The primary way of
determining CHC status is by self-identification (though some put it in their
name). The National Association of Community Health Centers (NACHC) does
maintain member lists as well. Non-profit and community board governance
are the key features.
1=Yes
2=No
3=Unknown/Missing
66
P2_ProvFQHC
Is facility/provider a Federally Qualified Health Center (FQHC)?
Federally qualified health centers (FQHCs) include all organizations receiving
grants under Section 330 of the Public Health Service Act (PHS). These are a
matter of public record and lists are available from HRSA
1=Yes
2=No
3=Unknown/Missing
67
P2_ProvPTXvisitDte
Date of patient initial visit for this issue, can be supplied/filled in from
This should be coded as a ‘SAS’ numeric date.
68
P2_ProvClinType
What was the category of provider examining/treating this patient (e.g.
1=MD
2=RN
3=PA
4=ARNP
5=LPN
6=Other
7=Unknown/Not Ascertained
69
P2_ProvPTX_GenderSP
Provider documented gender of sex partners
1=Males only
2=Females only
3=Both Males and Females
4=Not Documented
70
P2_ProvPTX_Insure
Insurance status of patient from provider's records
1=Yes, Insured
2=No, Not Insured
3=Unknown/Missing
71
P2_Urethritis
Was urethritis found on exam
Missing/unknown information code as null (‘.’).
1=Yes
2=No
72
P2_Proctitis
Was proctitis found on exam
Missing/unknown information code as null (‘.’).
1=Yes
2=No
Form Approved
OMB No. 0920-1072
Expiration Date ##/##/20##
SSuN Protocol (V10.0)
73
P2_Epididymitis
Was epididymitis found on exam
Missing/unknown information code as null (‘.’).
1=Yes
2=No
74
P2_PID
Was PID diagnosed.
Missing/unknown information code as null (‘.’).
1=Yes
2=No
75
P2_Discharge
Was discharge found on exam
Missing/unknown information code as null (‘.’).
1=Yes
2=No
76
P2_OtherFinding
Were there other STD-related findings on exam
Missing/unknown information code as null (‘.’).
1=Yes
2=No
77
P2_NoFinding
Were there no findings on exam
Missing/unknown information code as null (‘.’).
1=Yes
2=No
78
P2_ProvScrnUreth
Was patient screened/tested for infection at urethral site
1=Yes
2=No
3=Unknown
4=Refused
79
P2_ProvScrnVagCerv
Was patient screened/tested for infection at vaginal/cervical site
1=Yes
2=No
3=Unknown
4=Refused
80
P2_ProvScrnAnal
Was patient screened/tested for infection at anorectal site
1=Yes
2=No
3=Unknown
4=Refused
81
P2_ProvScrnPhar
Was patient screened/tested for infection at pharyngeal site
1=Yes
2=No
3=Unknown
4=Refused
82
P2_ProvScrnHIV
Was patient screened/tested for HIV infection at time of visit
1=Yes
2=No
3=Unknown
4=Refused
83
P2_ProvPTX_TxDte
Treatment date
This should be coded as a ‘SAS’ numeric date. Missing/unknown information
code as null (‘.’).
84
P2_ProvPTX_CFTRI
Was patient treated with ceftriaxone?
Missing/unknown information code as null (‘.’).
Form Approved
OMB No. 0920-1072
Expiration Date ##/##/20##
SSuN Protocol (V10.0)
1=Yes
2=No
85
P2_ProvPTX_CFTRI_DS
Ceftriaxone dosage
Missing/unknown information code as null (‘.’).
1=125mg
2=250mg
3=500mg
86
P2_ProvPTX_Azit
Was patient treated with azithromycin
Missing/unknown information code as null (‘.’).
1=Yes
2=No
87
P2_ProvPTX_Azit_DS
Azithromycin dosage
Missing/unknown information code as null (‘.’).
1=1 gram
2=2 grams
88
P2_ProvPTX_Doxy
Was patient treated with doxycycline?
Missing/unknown information code as null (‘.’).
1=Yes
2=No
89
P2_ProvPTX_Cefx
Was patient treated with cefixime?
Missing/unknown information code as null (‘.’).
1=Yes
2=No
90
P2_ProvPTX_Oth
Were other medications prescribed/provided for treating GC
Missing/unknown information code as null (‘.’).
1=Yes
2=No
91
P2_ProvPTX_OtherTXT
Specific other medications prescribed/provided for treating GC (text)
92
P2_ProvPTX_PDPT
Were any medications/prescriptions provided for patient's partner(s)?
Missing/unknown information code as null (‘.’).
1=Yes
2=No
93
P2_ProvPTX_HIBC
Was patient counseled to prevent transmission/reinfection?
Missing/unknown information code as null (‘.’).
1=Yes
2=No
94
P2_ProvPTX_Refer
Was patient referred to HD (or other) for partner services?
Missing/unknown information code as null (‘.’).
1=Yes
2=No
Population Component – Phase 3 – Patient Interview
95
1P3_IDX_ID
(1) Interviewer/Investigator ID
This is a locally assigned ID to uniquely identify the person conducting patient
interview. This data element should not be ‘null’ or contain missing values for
interviewed cases.
96
P3_PatientID
(2)Unique identifier for person/patient
Form Approved
OMB No. 0920-1072
Expiration Date ##/##/20##
SSuN Protocol (V10.0)
Will be a secondary key for merging data; should correspond to P1_PatientID.
This data element should not be ‘null’ or contain missing values for interviewed
cases.
97
P3_EventID
(3) Unique identifier for record
Will be a primary key for merging data; should correspond to P1_EventID.
This data element should not be ‘null’ or contain missing values for interviewed
cases.
98
P3_IDX_CADate1
(4) Contact attempt date 1
This data element should not be ‘null’ or contain
99
P3_IDX_CAout1
(5) Contact attempt outcome 1
This data element should not be ‘null’ or contain missing values for interviewed
cases.
0=Answer/Partial or Complete Interview Obtained
1=No Answer/No Message
2=No Answer/Message Left
3=Answer/Hang up
4=Answer/Refusal
5=Answer/Reschedule DIS call-back
6=Answer/Reschedule Patient Callback
7=Number out of service
8=Other
100
P3_IDX_CADate2
(6) Contact attempt date 2
This should be coded as a ‘SAS’ numeric date.
101
P3_IDX_CAout2
(7) Contact attempt outcome 2
0=Answer/Partial or Complete Interview Obtained
1=No Answer/No Message
2=No Answer/Message Left
3=Answer/Hang up
4=Answer/Refusal
5=Answer/Reschedule DIS call-back
6=Answer/Reschedule Patient Callback
7=Number out of service
8=Other
102
P3_IDX_CADate3
(8) Contact attempt date 3
This should be coded as a ‘SAS’ numeric date.
103
P3_IDX_CAout3
(9) Contact attempt outcome 3
0=Answer/Partial or Complete Interview Obtained
1=No Answer/No Message
2=No Answer/Message Left
3=Answer/Hang up
4=Answer/Refusal
5=Answer/Reschedule DIS call-back
6=Answer/Reschedule Patient Callback
7=Number out of service
8=Other
104
P3_IDX_CADate4
(10) Contact attempt date 4
This should be coded as a ‘SAS’ numeric date.
105
P3_IDX_CAout4
(11) Contact attempt outcome 4
0=Answer/Partial or Complete Interview Obtained
1=No Answer/No Message
2=No Answer/Message Left
3=Answer/Hang up
4=Answer/Refusal
5=Answer/Reschedule DIS call-back
6=Answer/Reschedule Patient Callback
7=Number out of service
8=Other
106
P3_IDX_Ixdate
(12) Interview/Disposition Date
Form Approved
OMB No. 0920-1072
Expiration Date ##/##/20##
SSuN Protocol (V10.0)
This should be coded as a ‘SAS’ numeric date.
107
P3_IDX_Dispo
(13) Phase 3 investigation/Interview Disposition
Should not be ‘null’ for cases included in random sample.
0=Investigation complete: patient contacted, interview
1=Investigation complete: patient contacted, partial interview
10=Investigation not complete: P3 investigation pending
11=Investigation not complete: patient contacted, refused
12=Investigation not complete: patient contacted, unable to
22=Investigation not complete: patient did not respond to at
33=Investigation not complete: patient contact not initiated
44=Investigation not complete: patient contact not initiated
55=Investigation not complete: >60 days from diagnosis
66=Investigation not complete: case determined to be OOJ
77=Investigation not complete: insufficient contact information
88=Investigation not complete: provider refused patient contact
99=Investigation not complete: administrative closure/other
108
P3_PTX_age
(14) What is your age?
This data element should not be ‘null’ or contain missing values for interviewed
cases. May be ‘Null’ if #107 (P3_IDX_Dispo) = ‘1’, partial interview.
888=Refused
109
P3_PTX_sex
(15) What gender or sex do you consider yourself to be?
1=Male
2=Female
3=Male-to-Female TG
4=Female-to-Male TG
5=TG Unknown or Unspecified
8=Refused
110
P3_PTX_HispEthnic
(16) Do you consider yourself to be Hispanic or Latino/a?
This data element should not be ‘null’ or contain missing values for interviewed
cases. May be ‘Null’ if #107 (P3_IDX_Dispo) = ‘1’, partial interview.
1=Yes
2=No
3=Unknown
4=Refused
111
P3_PTX_White
(17) patient reported White race
This data element should not be ‘null’ or contain missing values for interviewed
cases. May be ‘Null’ if #107 (P3_IDX_Dispo) = ‘1’, partial interview.
1=Yes
2=No
3=Unknown
4=Refused
112
P3_PTX_Black
(18) patient reported Black race
This data element should not be ‘null’ or contain missing values for interviewed
cases. May be ‘Null’ if #107 (P3_IDX_Dispo) = ‘1’, partial interview.
1=Yes
2=No
3=Unknown
4=Refused
113
P3_PTX_AIAN
(19) patient reported AIAN race
This data element should not be ‘null’ or contain missing values for interviewed
cases. May be ‘Null’ if #107 (P3_IDX_Dispo) = ‘1’, partial interview.
1=Yes
2=No
Form Approved
OMB No. 0920-1072
Expiration Date ##/##/20##
SSuN Protocol (V10.0)
3=Unknown
4=Refused
114
P3_PTX_Asian
(20) patient reported Asian race
This data element should not be ‘null’ or contain missing values for interviewed
cases. May be ‘Null’ if #107 (P3_IDX_Dispo) = ‘1’, partial interview.
1=Yes
2=No
3=Unknown
4=Refused
115
P3_PTX_NHOPI
(21) patient reported NHOPI race
This data element should not be ‘null’ or contain missing values for interviewed
cases. May be ‘Null’ if #107 (P3_IDX_Dispo) = ‘1’, partial interview.
1=Yes
2=No
3=Unknown
4=Refused
116
P3_PTX_OTHrace
(22) patient reported other race
This data element should not be ‘null’ or contain missing values for
interviewed cases. May be ‘Null’ if #107 (P3_IDX_Dispo) = ‘1’, partial
interview. Code as 1 if anything specified by patient is not otherwise
captured above.
1=Yes
2=No
3=Unknown
4=Refused
117
P3_PTX_RefRace
(23) patient refuses provision of all race information
This data element should not be ‘null’ or contain missing values for interviewed
cases. May be ‘Null’ if #107 (P3_IDX_Dispo) = ‘1’, partial interview.
1=Yes
2=No
118
P3_PTX_Insure
(24) Do you have any kind of health care coverage, including health
insurance, prepaid plans such as HMOs, or government plans such as
Medicare, Indian Health Services, the V.A. or Military?
This data element should not be ‘null’ or contain missing values for interviewed
cases. May be ‘Null’ if #107 (P3_IDX_Dispo) = ‘1’, partial interview.
1=Yes
2=No
3=Don't Know /Don't Remember/ Not Sure
4=Refused
119
P3_PTX_InsType
(25) What kind of healthcare insurance do you have?
This data element should not be ‘null’ or contain missing values for interviewed
cases. May be ‘Null’ if #107 (P3_IDX_Dispo) = ‘1’, partial interview.
1=Private healthcare insurance provided by my employer
2=Private healthcare insurance I pay for myself
3=Public healthcare insurance like Medicaid, Medicare, or a
4=Active or retired military or dependent plan like the V.A. or
5=Bureau of Indian Affairs/IHS/Urban Indian Health
7=Other
8=Don‘t know / Not sure
9=Refused
120
P3_PTX_OthInsSpecify
(25a) Other type of insurance (text)
121
P3_PTX_PriCareDoc
(26) Do you have one person you think of as your personal doctor or health
care provider?
Form Approved
OMB No. 0920-1072
Expiration Date ##/##/20##
SSuN Protocol (V10.0)
This data element should not be ‘null’ or contain missing values for interviewed
cases. May be ‘Null’ if #107 (P3_IDX_Dispo) = ‘1’, partial interview.
1=Yes, only one
2=More than one or facility
3=No
4=Don't Know /Not Sure
5=Refused
122
P3_PTX_Hccost
(27) Was there a time in the past 12 months when you needed to see a
doctor but could not because of cost?
This data element should not be ‘null’ or contain missing values for interviewed
cases. May be ‘Null’ if #107 (P3_IDX_Dispo) = ‘1’, partial interview.
1=Yes
2=No
3=Don't Know /Don't Remember/ Not Sure
4=Refused
123
P3_PTX_OOPE
(28) When you went to see _______________ (mention provider, clinic or
facility name) when you were diagnosed with gonorrhea, did you need to pay
anything out-of-pocket at the time of your visit?
This data element should not be ‘null’ or contain missing values for interviewed
cases. May be ‘Null’ if #107 (P3_IDX_Dispo) = ‘1’, partial interview.
1=Yes
2=No
3=Don't Know /Don't Remember/ Not Sure
4=Refused
124
NEW
P3_PTX_SYMP1
(28.1) Before you went to see _______________ (mention provider, clinic or
facility name) when you were diagnosed with gonorrhea, did you have any
unusual discharge or oozing from your (penis/vagina)?
This data element should not be ‘null’ or contain missing values for interviewed
cases. May be ‘Null’ if #107 (P3_IDX_Dispo) = ‘1’, partial interview.
1=Yes
2=No
3=Don't Know /Don't Remember/ Not Sure
4=Refused
125
NEW
P3_PTX_SYMP2
(28.2) Before you went to see _______________ (mention provider, clinic or
facility name) did you notice any unexplained sores or bumps on your
(penis/vagina)?
This data element should not be ‘null’ or contain missing values for interviewed
cases. May be ‘Null’ if #107 (P3_IDX_Dispo) = ‘1’, partial interview.
1=Yes
2=No
3=Don't Know /Don't Remember/ Not Sure
4=Refused
4=Refused
126
NEW
P3_PTX_SYMP3
(28.3) Before you went to see _______________ (mention provider, clinic or
facility name) when you were diagnosed with gonorrhea, did you have any pain
or burning when you urinated?
This data element should not be ‘null’ or contain missing values for interviewed
cases. May be ‘Null’ if #107 (P3_IDX_Dispo) = ‘1’, partial interview.
1=Yes
2=No
3=Don't Know /Don't Remember/ Not Sure
4=Refused
4=Refused
Form Approved
OMB No. 0920-1072
Expiration Date ##/##/20##
SSuN Protocol (V10.0)
127
P3_PTX_SYMP
(29) Did you go to the doctor that time because you were having symptoms or
pains you thought might be from an STD
This data element should not be ‘null’ or contain missing values for interviewed
cases. May be ‘Null’ if #107 (P3_IDX_Dispo) = ‘1’, partial interview.
1=Yes
2=No
3=Don't Know /Don't Remember/ Not Sure
4=Refused
4=Refused
128
P3_PTX_Delay
(30) How long did you have these symptoms or pains before you were able to
see the doctor?
This data element should not be ‘null’ or contain missing values for interviewed
cases. May be ‘Null’ if #107 (P3_IDX_Dispo) = ‘1’, partial interview.
1=1 Day
2=2 - 6 Days
3=1 - 2 weeks
4=More than 2 weeks
5=Don‘t know / Not sure / Don’t remember
6=Refused
129
P3_PTX_ExpSTD
(31) Before you went to the doctor that time, did any of your sex partners tell
you that you might have been exposed to an STD?
This data element should not be ‘null’ or contain missing values for interviewed
cases. May be ‘Null’ if #107 (P3_IDX_Dispo) = ‘1’, partial interview.
1=Yes
2=No
3=Don't Know /Don't Remember/ Not Sure
4=Refused
130
P3_PTX_reasA
(32) Reason for going to specific doctor: regular doctor: Because this is your
usual/regular doctor.
This data element should not be ‘null’ or contain missing values for interviewed
cases. May be ‘Null’ if #107 (P3_IDX_Dispo) = ‘1’, partial interview.
1=Yes
2=No
131
P3_PTX_reasB
(33) Reason for going to doctor: Because you could get seen for free?
This data element should not be ‘null’ or contain missing values for interviewed
cases. May be ‘Null’ if #107 (P3_IDX_Dispo) = ‘1’, partial interview.
1=Yes
2=No
132
P3_PTX_reasC
(34) Reason for going to doctor: Because they take your insurance?
This data element should not be ‘null’ or contain missing values for interviewed
cases. May be ‘Null’ if #107 (P3_IDX_Dispo) = ‘1’, partial interview.
1=Yes
2=No
133
P3_PTX_reasD
(35) Reason for going to specific doctor: Because you felt more comfortable
about your privacy there?
This data element should not be ‘null’ or contain missing values for interviewed
cases. May be ‘Null’ if #107 (P3_IDX_Dispo) = ‘1’, partial interview.
1=Yes
2=No
Form Approved
OMB No. 0920-1072
Expiration Date ##/##/20##
SSuN Protocol (V10.0)
134
P3_PTX_reasE
(36) Reason for going to specific doctor: Because you could get seen right
away?
This data element should not be ‘null’ or contain missing values for interviewed
cases. May be ‘Null’ if #107 (P3_IDX_Dispo) = ‘1’, partial interview.
1=Yes
2=No
135
P3_PTX_reasF
(37) Reason for going to specific doctor: Because you wanted to see an expert
specializing in STDs.
This data element should not be ‘null’ or contain missing values for interviewed
cases. May be ‘Null’ if #107 (P3_IDX_Dispo) = ‘1’, partial interview.
1=Yes
2=No
136
P3_PTX_reasI
(38) Reason for going to specific doctor: Because this doctor is close to your
house and easy to get to.
This data element should not be ‘null’ or contain missing values for interviewed
cases. May be ‘Null’ if #107 (P3_IDX_Dispo) = ‘1’, partial interview.
1=Yes
2=No
137
P3_PTX_reasG
(39) Reason for going to specific doctor: Because you were embarrassed and
didn’t want to go to your regular doctor.
This data element should not be ‘null’ or contain missing values for interviewed
cases. May be ‘Null’ if #107 (P3_IDX_Dispo) = ‘1’, partial interview.
1=Yes
2=No
138
P3_PTX_reasH
(40) Reason for going to specific doctor: Because I didn’t want the insurance
papers/info sent to my home/parents.
This data element should not be ‘null’ or contain missing values for interviewed
cases. May be ‘Null’ if #107 (P3_IDX_Dispo) = ‘1’, partial interview.
1=Yes
2=No
139
P3_PTX_reasJ
(41) Reason for going to specific doctor: Any other reason?
This data element should not be ‘null’ or contain missing values for interviewed
cases. May be ‘Null’ if #107 (P3_IDX_Dispo) = ‘1’, partial interview.
1=Yes
2=No
140
P3_PTX_othReasonText
(42) Other reason text.
141
P3_PTX_refusreason
(43) Refused all reasons
This data element should not be ‘null’ or contain missing values for interviewed
cases. May be ‘Null’ if #107 (P3_IDX_Dispo) = ‘1’, partial interview.
1=Yes
2=No
142
P3_PTX_PartnerTest
(44) Did the doctor, nurse or anyone else during that visit talk to you about the
importance of getting your sex partners examined and tested for STDs?
This data element should not be ‘null’ or contain missing values for interviewed
cases. May be ‘Null’ if #107 (P3_IDX_Dispo) = ‘1’, partial interview.
1=Yes
2=No
3=Don't Know /Don't Remember/ Not Sure
Form Approved
OMB No. 0920-1072
Expiration Date ##/##/20##
SSuN Protocol (V10.0)
4=Refused
143
P3_PTX_TellParts
(45) In the time since your visit, did you tell any of your sex partners they may
need to tested or treated for STDs?
This data element should not be ‘null’ or contain missing values for interviewed
cases. May be ‘Null’ if #107 (P3_IDX_Dispo) = ‘1’, partial interview.
1=Yes
2=No
3=Don't Know /Don't Remember/ Not Sure
4=Refused
144
P3_PTX_EPToffer
(46) Did a doctor, nurse or someone at the health department offer to give you
medications or a prescription for you to give to any of your sex partner(s)?
This data element should not be ‘null’ or contain missing values for interviewed
cases. May be ‘Null’ if #107 (P3_IDX_Dispo) = ‘1’, partial interview.
1=Yes
2=No
3=Don't Know /Don't Remember/ Not Sure
4=Refused
145
P3_PTX_EPTWHO
(47) Who was it that offered you the additional medications or prescriptions?
Was it someone from your doctor’s office or someone from the health
department?
This data element should not be ‘null’ or contain missing values for interviewed
cases. May be ‘Null’ if #107 (P3_IDX_Dispo) = ‘1’, partial interview.
1=My doctor’s office
2=The health department
3=Someone else
4=Don‘t know / Not sure
5=Refused
146
P3_PTX_EPTGET
(48) Did you actually get the additional medications or prescriptions for your
sex partners?
This data element should not be ‘null’ or contain missing values for interviewed
cases. May be ‘Null’ if #107 (P3_IDX_Dispo) = ‘1’, partial interview.
1=Yes
2=No
3=Don't Know /Don't Remember/ Not Sure
4=Refused
147
P3_PTX_EPTMEDORRX
(49) Did you get medicine to give to your partner? Or did you get prescriptions
that your partners needed to have filled at a pharmacy?
This data element should not be ‘null’ or contain missing values for interviewed
cases. May be ‘Null’ if #107 (P3_IDX_Dispo) = ‘1’, partial interview.
1=I got additional medications
2=I got prescription(s)
3=Don‘t know / Not sure
148
P3_PTX_EPTGAVE
(50) Did you give the additional medications or prescriptions to at least one of
your sex partners?
This data element should not be ‘null’ or contain missing values for interviewed
cases. May be ‘Null’ if #107 (P3_IDX_Dispo) = ‘1’, partial interview.
1=Yes
2=No
9=Refused
149
P3_PTX_HIVtested
(52) Did you get tested for HIV at that visit?
Form Approved
OMB No. 0920-1072
Expiration Date ##/##/20##
SSuN Protocol (V10.0)
This data element should not be ‘null’ or contain missing values for interviewed
cases. May be ‘Null’ if #107 (P3_IDX_Dispo) = ‘1’, partial interview.
1=Yes
2=No
3=Don't Know /Don't Remember/ Not Sure
4=Refused
150
P3_PTX_HIVresult
(53) What was the result of your HIV test at that visit?
This data element should not be ‘null’ or contain missing values if #145=1.
1=Positive
2=Negative
3=Don't Know / Not Sure / did not get results
4=Refused
151
P3_PTX_everHIVtst
(54) Have you ever been tested for HIV?
May be ‘Null’ if #145=1. This data element should not be ‘null’ or contain
missing values for cases responding with 2, 3 or 4 to #145.
1=Yes
2=No
3=Don't Know /Don't Remember/ Not Sure
4=Refused
152
P3_PTX_whenHIVtest
(55) When was your last HIV test? Just month and year is ok? (IF PATIENT
UNABLE TO RECALL, PROBE UNTIL APPROXIMATE RESPONSE ELICITED)
May be ‘Null’ if #147=2, 3 or 4. This should be character data ”MM/YYYY”,
missing/REFUSED information as”../YYYY” or “../….”
153
P3_PTX_HIVeverResult
(56) What was the result of that HIV test?
This data element should not be ‘null’ or contain missing values for cases
responding to #147=1.
1=Positive
2=Negative
3=Don't Know / Not Sure / did not get results
4=Refused
154
P3_PTX_inHIVcare
(57) When was your most recent visit to a doctor, nurse or other health
This data element should not be ‘null’ or contain missing values for cases
identifying as HIV positive (146=1 or 149=1). This should be entered as
character data ”MM/YYYY”, missing/REFUSED information as”../YYYY” or
“../….”
155
P3_PTX_ART
(58) Are you taking antiretroviral medicines to treat your HIV infection?
This data element should not be ‘null’ or contain missing values for cases
identifying as HIV positive (146=1 or 149=1). This should be entered as
character data ”MM/YYYY”, missing/REFUSED information as”../YYYY” or
“../….”
1=Yes
2=No
3=Don't Know /Don't Remember/ Not Sure
4=Refused
156
NEW
P3_PTX_PrEP
(58.1) When you were diagnosed with gonorrhea, did your health care provider
or anyone else discuss medications to help you prevent getting HIV? This is
often called PrEP, or pre-exposure prophylaxis.
This data element should be ‘null’ for patients reporting being HIV positive. This
data element should not be ‘null’ or contain missing values for patients
identifying as HIV negative or unknown HIV status (146=2, 3 or 4; 149=2, 3 or
4).
1=Yes
2=No
3= Don‘t know / Not sure
4=Refused
157
NEW
P3_PTX_PREP1
(58.2) Did your health care provider prescribe or give you
medications to help you prevent getting HIV?
Form Approved
OMB No. 0920-1072
Expiration Date ##/##/20##
SSuN Protocol (V10.0)
This data element should not be ‘null’ or contain missing values for
1=Yes
2=No
3=Don't Know /Don't Remember/ Not Sure
4=Refused
158
NEW
P3_PTX_PREP2
(58.3) Did you fill a prescription or get medications to help you prevent getting
HIV?
This data element should not be ‘null’ or contain missing values for those
answering “Yes” to #58.1.
1=Yes
2=No
3=Don't Know /Don't Remember/ Not Sure
4=Refused
159
NEW
P3_PTX_PREP3
(58.4) Are you currently taking daily medications to help you prevent
getting HIV (on PrEP)?
This data element should not be ‘null’ or contain missing values.
1=Yes
2=No
3=Don't Know /Don't Remember/ Not Sure
4=Refused
160
P3_PTX_Pregnant
(59) Were you pregnant at the time you were told that you had gonorrhea?
This data element should not be ‘null’ or contain missing value for female
cases interviewed. May be null for partial interviews, must be null for male
cases.
1=Yes
2=No
3=Don't Know /Don't Remember/ Not Sure
4=Refused
161
P3_PTX_GenderSP
(60) During the past 12 months, have you had sex with only males, only
This data element should not be ‘null’ or contain missing values for interviewed
cases. May be ‘Null’ if #107 (P3_IDX_Dispo) = ‘1’, partial interview.
1=Males only
2=Females only
3=Both Males and Females
4=Unknown
9=refused
162
P3_PTX_Sxorient
(61) Do you consider yourself to be…
This data element should not be ‘null’ or contain missing values for interviewed
cases. May be ‘Null’ if #107 (P3_IDX_Dispo) = ‘1’, partial interview.
1=Heterosexual/Straight
2=Gay/Lesbian/Homosexual
3=Bisexual
4=Other
9=Refused
163
P3_PTX_MaleSPL3MO
(62) Thinking back to the 3 months before you were diagnosed with
This data element should not be ‘null’ or contain missing values for
interviewed cases. May be ‘Null’ if #107 (P3_IDX_Dispo) = ‘1’, partial
interview. Probe for approximate response or ‘best’ guess. Enter 0 to indicate
‘None’, 9999 to indicate “Refused”.
164
P3_PTX_FemaleSPL3MO
(63) Thinking back to the 3 months before you were diagnosed with
This data element should not be ‘null’ or contain missing values for interviewed
cases. May be ‘Null’ if #107 (P3_IDX_Dispo) = ‘1’, partial interview. May be
‘Null’ if #107 (P3_IDX_Dispo) = ‘1’, partial interview. Probe for approximate
response or ‘best’ guess. Enter 0 to indicate ‘None’, 9999 to indicate
“Refused”.
Form Approved
OMB No. 0920-1072
Expiration Date ##/##/20##
SSuN Protocol (V10.0)
165
P3_PTX_SPtreatOne
(63.1) To the best of your knowledge, was your sex partner treated?
This data element is for patient reporting only a single sex partner.
1=Yes, definitely
2=Yes, probably
3=Don't Know / Not Sure
4=No, probably not
5=Refused
6=No need/no partners infected
166
P3_PTX_SPtreatMult
(63.2) To the best of your knowledge, would you say that all of your sex
partners were definitely treated, at least one of your partners was definitely
treated, or that none were treated?
This data element is for patients reporting multiple sex partners.
1=All definitely treated
2=At least one definitely treated
3=At least one probably treated
4=Not sure
5=Probably none treated
6=Refused
7=No need/no partners infected
167
P3_PTX_SexExch
(64) During the past 12 months, have you given drugs or money in exchange
for sex or received drugs or money in exchange for sex? By sex we mean
vaginal, oral, or anal sex.
This data element should not be ‘null’ or contain missing values for interviewed
cases. May be ‘Null’ if #107 (P3_IDX_Dispo) = ‘1’, partial interview.
1=Yes
2=No
3=Don't Know /Don't Remember/ Not Sure
4=Refused
168
168.1
NEW
NEW
P3_PTX_Opioid
P3_IVDU
(64.1) In the past year, how often have you used prescription pain medications
other than as prescribed by a doctor?
This data element should not be ‘null’ or contain missing values for interviewed
cases. May be ‘Null’ if #107 (P3_IDX_Dispo) = ‘1’, partial interview.
1=Never
2=Once or Twice
3=Monthly
4=Weekly
5=Daily or Almost Daily
9=Refused
In the past year, have you used any injection drugs such as heroin, cocaine or
meth?
1=Yes
2=No
3=Don’t Know/Can’t Remember
4=Refused
168.2
168.3
169
New
NEW
P3_IVDU_DR
In the past year, did you inject…(read all, check all that apply)?
P3_IVDU_DR_TX
1- Heroin
2- Cocaine/Crack
3- Crystal Meth/Methamphetamine
4- Morphine
5- Fentanyl/Carfentanil
6- Other
(description of other drug injected)
P3_PTX_LastSex
(65) When was the last time you had sex?
This data element should not be ‘null’ or contain missing values for interviewed
cases. May be ‘Null’ if #107 (P3_IDX_Dispo) = ‘1’, partial interview.
1=In last week
2=> 1 week but within last month
Form Approved
OMB No. 0920-1072
Expiration Date ##/##/20##
SSuN Protocol (V10.0)
3=> 1 month, but within 2 months
4=> 2 months ago
5=Don't Know / Not sure
9=Refused
170
P3_PTX_GenderMRSP
(66) Thinking back to the last time you had sex, was the person you had sex
with…(male/female)?
This data element should not be ‘null’ or contain missing values for interviewed
cases. May be ‘Null’ if #107 (P3_IDX_Dispo) = ‘1’, partial interview.
1=Male
2=Female
3=Male-to-Female TG
4=Female-to-Male TG
5=TG Unknown or Unspecified
9=Unknown
171
P3_PTX_AgeMRSP
(67) Thinking back to the last person you had sex with, how old do you think
that person is? If you don’t know for sure, it’s OK to make your best guess.
This data element should not be ‘null’ or contain missing values for interviewed
cases. May be ‘Null’ if #107 (P3_IDX_Dispo) = ‘1’, partial interview.
172
P3_PTX_HISPMRSP
(68) Would you say that person is Hispanic/Latino/a? If you don’t know for
sure, it’s OK to make your best guess.
This data element should not be ‘null’ or contain missing values for interviewed
cases. May be ‘Null’ if #107 (P3_IDX_Dispo) = ‘1’, partial interview.
1=Yes, Hispanic
2=No, Not Hispanic
8=Unknown/Can't guess
9=Refused
173
P3_PTX_RaceMRSP
(69) Thinking back to the last person you had sex with, what race(s) would you
say that person is? If you don’t know for sure, it’s OK to make your best guess.
This data element should not be ‘null’ or contain missing values for interviewed
cases. May be ‘Null’ if #107 (P3_IDX_Dispo) = ‘1’, partial interview.
1=White
2=Black
3=AI/AN
4=ASIAN
5=NH/OPI
7=Other race
8=Unknown/Can't guess
9=Refused
174
P3_PTX_MRSPHIV
(70) Thinking back to the last person you had sex with, do you know if that
person HIV positive?
This data element should not be ‘null’ or contain missing values for interviewed
cases. May be ‘Null’ if #107 (P3_IDX_Dispo) = ‘1’, partial interview.
1=Yes, I know that person is HIV positive
2=No, I know that person is HIV negative
3=Don't Know /Don't Remember/ Not Sure
4=Refused
175
P3_PTX_SexAgainMRSP
(71) Thinking back to the last person you had sex with; do you think you will
have sex with this person again?
This data element should not be ‘null’ or contain missing values for interviewed
cases. May be ‘Null’ if #107 (P3_IDX_Dispo) = ‘1’, partial interview.
1=Yes
2=No
3=Don't Know /Maybe/ Not Sure
4=Refused
Form Approved
OMB No. 0920-1072
Expiration Date ##/##/20##
SSuN Protocol (V10.0)
176
P3_PTX_GEOMRSP
(72) Thinking back to the last person you had sex with, about how far away
does that person live from you. If you don’t know for sure, it’s OK to make
your best guess.
This data element should not be ‘null’ or contain missing values for interviewed
cases. May be ‘Null’ if #107 (P3_IDX_Dispo) = ‘1’, partial interview.
0=Partner lives with me
1=less than 5 minutes
2=5 to 15 minutes
3=15 to 30 minutes
4=30 minutes to 1 hour
5=> 1 hour
6=They live in another state
7=They live in another country
8=Don't know / Not sure
9=Refused
177
P3_PTX_DIS_EPT
(73) Did the interviewer/DIS provide EPT/PDPT to patient?
This data element should not be ‘null’ or contain missing values for interviewed
cases. May be ‘Null’ if #107 (P3_IDX_Dispo) = ‘1’, partial interview.
1=Yes
2=No
178
P3_PTX_DIS_EPTnum
(74) Number of partners EPT provided for
This data element should not be ‘null’ or contain missing values for interviewed
cases. May be ‘Null’ if #107 (P3_IDX_Dispo) = ‘1’, partial interview.
179
P3_PTX_DIS_OtherPS
(75) Did interviewer/DIS provide other partner services to patient (DIS
referral?)
This data element should not be ‘null’ or contain missing values for interviewed
cases. May be ‘Null’ if #107 (P3_IDX_Dispo) = ‘1’, partial interview.
1=Yes
2=No
Population Component – Provider/Facility Metadata File (Annual)
180
P4_ProvID
Unique identifier for provider/facility
This data element MUST NOT be ‘null’ or contain missing values.
181
P4_ProvName
Name of provider or facility
182
P4_ProvCO
FIPS code for provider/facility physical location
183
P4_ProvZIP
Facility/provider physical location 5-digit ZIP
This data element should not be ‘null’ or contain missing values.
184
P4_UpdateDate
Date provider information last updated/verified
This data element should not be ‘null’ or contain missing values. This
185
P4_LocationLon
Provider physical location longitude
186
P4_LocationLat
Provider physical location latitude
187
P4_CensusTract
Census tract of provider physical location
188
P4_Prov_Fac_Type
Facility or provider type code (PHINVAD compatible)
This data element MUST NOT be ‘null’ or contain missing values.
1=Blood Bank
Includes for-profit sera collection centers
2=Correctional Facilities
Includes jails, prisons, juvenile detention, etc.
3=Day care center (environment)
4=Dentist
5=Drug Treatment Facility
Form Approved
OMB No. 0920-1072
Expiration Date ##/##/20##
SSuN Protocol (V10.0)
6=Emergency Room/Emergency Department
Include HMO/other urgent care in this category
7=Family Planning Facility
Includes reproductive health clinics
8=Other Federal Agencies
Do not include bureau of prisons in this category (should be 2,
9=HIV Care Facility
Includes and care facility whose primary service is HIV care
10=HIV Counseling and Testing Site
Include HIV outreach & street testing in this category
11=Hospital - Not ED/ER
This should include in-patient facilities where the patient was
12=Labor and Delivery
13=Laboratory
14=Managed Care/HMOs
15=Mental Health Provider
16=Military
17=National Job Training Program
18=Other, not otherwise specified
19=Other Health Department Clinic
Do not include health department clinics whose primary
20=Other State and Local Agencies
21=Other Treatment Center
22=Pharmacy
23=Prenatal/Obstetrics Facility
24=Private physicians' group office
25=Public Health Clinic
Include ONLY public clinics not otherwise categorized
26=Data/Disease Registries
27=Rural Health Clinic
Includes clinics specifically designated as RHCs on the Centers
28=Categorical STD Clinic
29=School-Based Clinic
30=TB Clinic
31=Tribal Government Clinic
Do not include IHS hospitals (those are coded as 32)
32=Indian Health Service
33=Veterinary Sources
34=Vital Statistics
99=unknown
189
P4_ProvCHC
Is facility/provider a Community Health Center (CHC)?
This data element should not be ‘null’ or contain missing values.
1=Yes
2=No
3=Unknown/Missing
190
P4_ProvFQHC
Is facility/provider a Federally Qualified Health Center (FQHC)?
This data element should not be ‘null’ or contain missing values.
1=Yes
2=No
3=Unknown/Missing
Facility Component – Patient Visit Records
191
F1_FacilityID
Unique facility identifier
This ID should be supplied by the site and is a unique facility identifier from
underlying surveillance systems or may be generated specifically for SSuN.
Regardless of source, this ID must be unique and allow for longitudinal
tracking of the facility. This data element MUST NOT be ‘null’ or contain
missing values.
192
F1_SiteID
Unique site code
BA=Baltimore
CA=California
FL=Florida
MA=Massachusetts
MN=Minnesota
MC=Multnomah county
Form Approved
OMB No. 0920-1072
Expiration Date ##/##/20##
SSuN Protocol (V10.0)
NY=New York City
PH=Philadelphia
SF=San Francisco
WA= Washington
VA=Virginia (Cycle II)
AL=Alabama (Cycle II)
CO=Colorado (Cycle II)
CH=Chicago (Cycle II)
This data element MUST NOT be ‘null’ or contain missing values.
193
F1_PatientID
Unique patient identification number assigned by site
This ID should be supplied by the site and may be a unique patient identifier
from underlying surveillance systems or may be generated specifically for
SSuN. Regardless of source, this ID must be unique and allow for longitudinal
tracking of patients within facilities. This data element MUST NOT be ‘null’ or
contain missing values.
194
F1_Visdate
Date of clinic visit
This data element MUST NOT be ‘null’ or contain missing values.
195
F1_EventID
Unique visit identification
This record ID should be supplied by the site and may be an event or
F1_sex_BC
What is the patient's sex documented by the birth certificate?
1= Male
2= Female
3=Intersex
4=Unknown
A response of 9 indicates the information is not captured or collected by the
facility or is not provided to SSuN. A response of null indicates that the
information is collected by the facility but is unknown for this record.
F1_Gender
What is the patient's gender?
196
197
NEW
1= Male
2= Female
3=Transgender M to F
4=Transgender F to M
5=Transgender unspecified
6= Other
9= Not captured
A response of 9 indicates the information is not captured or collected by the
facility or is not provided to SSuN. A response of null indicates that the
information is collected by the facility but is unknown for this record.
198
F1_Age
How old is the patient?(Age in years).
If age is unknown or missing, use null value.
199
F1_Hisp
Is the patient of Hispanic ethnicity?
1= Yes
2= No
9= Not captured
A response of 9 indicates the information is not captured or collected by the
facility or is not provided to SSuN. A response of null indicates that the
information is collected by the facility but is unknown for this record.
200
F1_AIAN
Is the patient American Indian or Alaskan Native?
1= Yes
2= No
9= Not captured
A response of 9 indicates the information is not captured or collected by the
facility or is not provided to SSuN. A response of null indicates that the
information is collected by the facility but is unknown for this record.
201
F1_Asian
Is the patient Asian?
1= Yes
2= No
9= Not captured
A response of 9 indicates the information is not captured or collected by the
facility or is not provided to SSuN. A response of null indicates that the
information is collected by the facility but is unknown for this record.
Form Approved
OMB No. 0920-1072
Expiration Date ##/##/20##
SSuN Protocol (V10.0)
202
F1_PIH
Is the patient Native Hawaiian or Pacific Islander?
1= Yes
2= No
9= Not captured
A response of 9 indicates the information is not captured or collected by the
facility or is not provided to SSuN. A response of null indicates that the
information is collected by the facility but is unknown for this record.
203
F1_Black
Is the patient Black?
1= Yes
2= No
9= Not captured
A response of 9 indicates the information is not captured or collected by the
facility or is not provided to SSuN. A response of null indicates that the
information is collected by the facility but is unknown for this record.
204
F1_White
Is the patient White?
1= Yes
2= No
9= Not captured
A response of 9 indicates the information is not captured or collected by the
facility or is not provided to SSuN. A response of null indicates that the
information is collected by the facility but is unknown for this record.
205
F1_Multirace
Is the patient Multirace?
1= Yes
2= No
9= Not captured
A response of 9 indicates the information is not captured or collected by the
facility or is not provided to SSuN. A response of null indicates that the
information is collected by the facility but is unknown for this record.
206
F1_Otherrace
Is the patient another race not listed above?
1= Yes
2= No
9= Not captured
For #199-206 indicate yes for all of the race/ethnic questions that apply. A
response of 9 indicates the information is not captured/ collected by the
facility or is not provided to SSuN. Response should be null if (1) race is
collected by the facility but is unknown for this record, or (2) a response of
“no” is not collected separately.
207
F1_Visit_type
Type of clinic visit
1 = Clinician
2= express/fast track
8= Other
9= Not captured
A response of 9 indicates the information is not captured or collected by the
facility or not provided to SSuN. A response of null indicates that the
information is collected but is unknown for this record.
208
F1_Reason_visit
What was the primary purpose of the visit?
1= Symptomatic/new problem
2= Treatment only
3= Follow-up
4= Family planning
5= STD/HIV screening only
6= Prenatal care
7=PrEP Visit
8= Other
9= Not captured
A response of 9 indicates the information is not captured or collected by the
facility or is not provided to SSuN. A response of null indicates that the
information is collected but is unknown for this record.
209
F1_Insurance
What is the primary health insurance status of the patient?
1= Insured, Public only
2= Insured, Private only
3= Insured, Multiple types
4=Unknown type
5=Uninsured
Form Approved
OMB No. 0920-1072
Expiration Date ##/##/20##
SSuN Protocol (V10.0)
9= Insurance status not captured
A response of 9 indicates the information is not captured or collected by the
facility or is not provided to SSuN. A response of null indicates that the
information is collected but is unknown for this record.
210
F1_HPVVaxadmin
Was the patient given HPV vaccination at this visit?
1= Yes
2= No, not indicated/refused
3= No, clinic does not administer/offer HPV vaccination
4=Not captured
A response of 9 indicates the information is not captured or collected by the
facility or is not provided to SSuN. A response of null indicates that the
information is collected but is unknown for this record.
211
F1_MENSEX
How many male sex partners has the patient had in the last 3 months?
If number of male sex partners is unknown, missing, or not captured, use null
value.
212
F1_FEMSEX
How many female sex partners has the patient had in the last 3
If number of female sex partners is unknown, missing, or not captured, use null value.
F1_TRANSEX
How many transgender sex partners has the patient had in the last 3 months?
213
NEW
If number of female sex partners is unknown, missing, or not captured, use
null value.
214
215
NEW
F1_MSM_12
Does the male patient have a history of having male sex partners in the
previous 12 months?
1= Yes
2= No
9= Not captured
A response of 9 indicates the information is not captured or collected by the
facility or is not provided to SSuN. Null values are allowed if the information
is collected by the facility but (1) is unknown for this record or (2) there is
not an opportunity for a “no” response (radio button), or 3(patient is a
female).
F1_SEXOR3
Has the patient had sex with men, women, or both over the past 3
1= Men
2= Women
3= Both
4= No sexual partners in the last 3 months
9= Not captured
A response of 9 indicates the information is not captured or collected by the
facility or is not provided to SSuN. A response of null indicates that the
information is collected by the facility but is unknown for this record.
216
F1_NUMSEX3
How many sex partners has the patient had in the past 3 months?
If number of sex partners is unknown, missing, or not captured, use null
value.
217
F1_SEXUALITY
Does the patient consider him/herself gay (homosexual), straight
1 = gay/homosexual
2= straight/heterosexual
3= bisexual
4= Other
9 = Not captured
A response of 9 indicates the information is not captured or collected by the
facility or is not provided to SSuN. A response of null indicates that the
information is collected by the facility but is unknown for this record.
218
F1_NewSex
Did the patient have a new sex partner in last 3 months?
1= Yes
2= No
9= Not captured
A response of 9 indicates the information is not captured or collected by the
facility or is not provided to SSuN. A response of null indicates that the (1)
information is collected by the facility but is unknown for this record or (2)
that there was not an opportunity for a “no” response (radio button).
Form Approved
OMB No. 0920-1072
Expiration Date ##/##/20##
SSuN Protocol (V10.0)
219
NEW
F1_HIV_partner
Does the patient report having sex with a known HIV positive partner in the last
12 months?
1= Yes
2= No
3= Unsure/ doesn’t know
9= Not captured
A response of 9 indicates the information is not captured or collected by the
facility or is not provided to SSuN. A response of null indicates that the (1)
information is collected by the facility but is unknown for this record or (2)
that there was not an opportunity for a “no” response (radio button).
220
NEW
F1_IVDU
Does the patient report use of injected drugs in the past 3 months?
1= Yes
2= No
3= Patient not sure/ unknown
9= Not captured
A response of 9 indicates the information is not captured or collected by the
facility or is not provided to SSuN. A response of null indicates that the (1)
information is collected by the facility but is unknown for this record or (2)
that there was not an opportunity for a “no” response (radio button).
221
NEW
F1_Opioid
Does the patient report opioid use in the past 3 months?
1= Yes
2= No
3= Patient not sure/ unknown
9= Not captured
A response of 9 indicates the information is not captured or collected by the
facility or is not provided to SSuN. A response of null indicates that the (1)
information is collected by the facility but is unknown for this record or (2)
that there was not an opportunity for a “no” response (radio button).
222
F1_Rectal_exposure
Does the patient report anal sex with a male in the last 3 months?
1= Yes
2= No
9= Not captured
A response of 9 indicates the information is not captured or collected by the
facility or is not provided to SSuN. A response of null indicates that the (1)
information is collected by the facility but is unknown for this record or (2)
that there was not an opportunity for a “no” response (radio button).
223
F1_Oral_Sex
Did the patient engage in receptive oral sex in last 3 months days?
1= Yes
2= No
9= Not captured
A response of 9 indicates the information is not captured or collected by the
facility or is not provided to SSuN. A response of null indicates that the (1)
information is collected by the facility but is unknown for this record or (2)
that there was not an opportunity for a “no” response (radio button).
224
F1_HIVTestdate
When was the patient's last (most recent) test for HIV (month and year)?
(excluding HIV testing on today’s visit)?
Null values are allowed if (1) response to #222 is either 2, 3, 9 or (2) patient
does not know/ or not sure of the date of most recent HIV test.
225
F1_HIVResultlast
What was the result of the patient's most recent test for HIV (excluding HIV
Testing on today's visit)?
0= Negative
1= Positive/preliminary positive
2= Patient doesn’t know/ not sure
9= Not captured
A response of 9 indicates the information is not captured or collected by the
facility or is not provided to SSuN. Null value are allowed if (1) response to
#222 is either 2, 3, 9 or (2) patient does not know/ or not sure of the result of
the most recent HIV test.
226
F1_HIVTest_refuse
Did the patient refuse an HIV test today?
Form Approved
OMB No. 0920-1072
Expiration Date ##/##/20##
SSuN Protocol (V10.0)
1= Yes
2= No
9= Not captured
A response of 9 indicates the information is not captured or collected by the
facility or is not provided to SSuN. Null values are allowed if the information
is collected by the facility but (1) is unknown for this record or (2) there is
not an opportunity for a “no” response (radio button).
227
NEW
F1_HIVcare
Is the patient currently in HIV care?
1= Yes
2= No
3= Patient is not HIV positive
4= Unknown
9= Not captured
A response of 9 indicates the information is not captured or collected by the
facility or is not provided to SSuN. Null values are allowed if the information
is collected by the facility but (1) is unknown for this record or (2) there is
not an opportunity for a “no” response (radio button).
228
NEW
F1_PrEP
Is the patient on PrEP?
1= Yes
2= No
9= Not captured
A response of 9 indicates the information is not captured or collected by the
facility or is not provided to SSuN. Null values are allowed if the information
is collected by the facility but (1) is unknown for this record or (2) there is
not an opportunity for a “no” response (radio button).
229
NEW
F1_Prep_referral
Was the patient referred for PrEP at the STD clinic?
1= Yes
2= No
3= No, but a referral to outside clinic was given
9= Not captured
A response of 9 indicates the information is not captured or collected by the
facility or is not provided to SSuN. Null values are allowed if the information
is collected by the facility but (1) is unknown for this record or (2) there is
not an opportunity for a “no” response (radio button).
Is the patient (female) pregnant today?
1= Yes
2= No
3= Patient doesn’t know/not sure
9= Not captured
If information is collected but patient is not sure, then appropriate response
is 3. A response of 9 indicates the information is not captured or collected by
the facility or is not provided to SSuN. Null values allowed for men or if
information is collected by the facility but unknown for this record.
230
F1_Pregnant
231
F1_Sympt
Does the patient have STI symptoms?
1= Yes
2= No
9= Not captured
A response of 9 indicates the information is not captured or collected by the
facility or is not provided to SSuN. A response of null indicates that the
information is collected by the facility but is unknown for this record.
232
F1_Physical_exam
Was a physical exam performed on today's visit?
1= Yes
2= No
9= Not captured
233
F1_Contact_STD
Was the patient a contact or exposed to a STD?
1= Yes
2= No
9= Not captured
A response of 9 indicates the information is not captured or collected by the
facility or is not provided to SSuN. A response of null indicates that the
information is collected by the facility but is unknown for this record.
F1_EPT
Is the patient eligible for expediated partner therapy?
1= Yes
234
NEW
Form Approved
OMB No. 0920-1072
Expiration Date ##/##/20##
SSuN Protocol (V10.0)
2= No
3= No, not indicated
9= Not captured
A response of 9 indicates that EPT is provided by the facility, but information
is not captured or collected or is not provided to SSuN. A response of null
indicates that the (1) information is collected by the facility but is unknown
for this record, (2) facility does not provide EPT, or (3) information is
collected by the facility but there is not an opportunity for a “no” response
(radio button).
235
F1_Partner_TX
Was the patient prescribed or given a medication for expedited partner
therapy?
1= Yes
2= No
9= Not captured
A response of 9 indicates that EPT is provided by the facility, but information
is not captured or collected or is not provided to SSuN. A response of null
indicates that the (1) information is collected by the facility but is unknown
for this record, (2) facility does not provide EPT, or (3) information is
collected by the facility but there is not an opportunity for a “no” response
(radio button).
236
F1_SXRectal
Did the patient report any rectal symptoms today?
1= Yes
2= No
9= Not captured
A response of 9 indicates the information is not captured or collected by the
facility or is not provided to SSuN. Null values are allowed if the information
is collected by the facility but (1) is unknown for this record or (2) there is
not an opportunity for a “no” response (radio button).
237
F1_SXPharyngeal
Does the patient report any oral symptoms (e.g., sore throat) today?
1= Yes
2= No
9= Not captured
A response of 9 indicates the information is not captured or collected by the
facility or is not provided to SSuN. Null values are allowed if the information
is collected by the facility but (1) is unknown for this record or (2) there is
not an opportunity for a “no” response (radio button).
238
F1_SXDysuria
Does the patient report dysuria today?
1= Yes
2= No
9= Not captured
A response of 9 indicates the information is not captured or collected by the
facility or is not provided to SSuN. Null values are allowed if the information
is collected by the facility but (1) is unknown for this record or (2) there is
not an opportunity for a “no” response (radio button).
239
F1_SXDischarge
Does the patient report genital discharge today?
1= Yes
2= No
9= Not captured
A response of 9 indicates the information is not captured or collected by the
facility or is not provided to SSuN. Null values are allowed if the information
is collected by the facility but (1) is unknown for this record or (2) there is
not an opportunity for a “no” response (radio button).
240
F1_SXLesion
Does the patient report a genital lesion today?
1= Yes
2= No
9= Not captured
A response of 9 indicates the information is not captured or collected by the
facility or is not provided to SSuN. Null values are allowed if the information
is collected by the facility but (1) is unknown for this record or (2) there is
not an opportunity for a “no” response (radio button).
241
F1_PEDischarge
Was there a vaginal discharge seen on physical exam?
1= Yes
2= No
9= Not captured
Form Approved
OMB No. 0920-1072
Expiration Date ##/##/20##
SSuN Protocol (V10.0)
A response of 9 indicates the information is not captured or collected by the
facility or is not provided to SSuN. Null values are allowed if the information
is collected by the facility but (1) is unknown for this record or (2) there is
not an opportunity for a “no” response (radio button).
242
F1_PEAbdomen
Was there lower abdominal pain on exam?
1= Yes
2= No
9= Not captured
A response of 9 indicates the information is not captured or collected by the
facility or is not provided to SSuN. Null values are allowed if the information
is collected by the facility but (1) is unknown for this record or (2) there is
not an opportunity for a “no” response (radio button).
243
F1_PECMT
Was there cervical motion tenderness on exam?
1= Yes
2= No
9= Not captured
A response of 9 indicates the information is not captured or collected by the
facility or is not provided to SSuN. Null values are allowed if the information
is collected by the facility but (1) is unknown for this record or (2) there is
not an opportunity for a “no” response (radio button).
244
F1_PEAdnexal
Was there adnextal tenderness on exam?
1= Yes
2= No
9= Not captured
A response of 9 indicates the information is not captured or collected by the
facility or is not provided to SSuN. Null values are allowed if the information
is collected by the facility but (1) is unknown for this record or (2) there is
not an opportunity for a “no” response (radio button).
245
F1_GISP_yrmo
What is the Year/Month isolate was collected?
This data element pertains only to facilities participating in GISP and refers to
the year and the month the GISP specimen was collected. This data element
should not be ‘null’ or contain missing values for GISP patients.
246
F1_GISP_number
What is the Patients GISP number?
This data element pertains only to facilities participating in GISP and refers to
the GISP ID supplied by the site. This data element should not be ‘null’ or
contain missing values for GISP patients.
247
F1_GISP_Travel
Has the patient traveled outside of the United States (50 US States) dring the
previous 60 days?
1= Yes
2= No
9= Not captured
Null values are allowed for (1) non-GISP patients or (2) GISP patients when
the information is collected but unavailable for patient record. A response of
9 indicates the information is not captured or collected by the facility or is
not provided to SSuN.
248
F1_GISP_Sex_Work
Does the patient have a history of giving or receiving drugs/money for sex in
the previous 12 months?
1= Yes
2= No
9= Not captured
Null values are allowed for (1) non-GISP patients or (2) GISP patients when
the information is collected but unavailable for patient record. A response of
9 indicates the information is not captured or collected by the facility or is
not provided to SSuN.
249
F1_GISP_Antibiotic
Has the patient had any antibiotic use during the previous 60 days?
1= Yes
2= No
9= Not captured
Null values are allowed for (1) non-GISP patients or (2) GISP patients when
the information is collected but unavailable for patient record. A response of
9 indicates the information is not captured or collected by the facility or is
not provided to SSuN.
Form Approved
OMB No. 0920-1072
Expiration Date ##/##/20##
SSuN Protocol (V10.0)
250
F1_GISP_NON_IDU
Does the patient have a history of non-injection drug use in the previous 12
months?
1= Yes
2= No
9= Not captured
Null values are allowed for (1) non-GISP patients or (2) GISP patients when
the information is collected but unavailable for patient record. A response of
9 indicates the information is not captured or collected by the facility or is
not provided to SSuN.
251
F1_GISP_GC_12
How many previous episodes of gonorreha are documented in the patient's
medical record within the past 12 months?
Null values allowed (1) for non-GISP patients, (2) for GISP patients when the
information is collected but unavailable for patient record, or (3) if
information is not captured by underlying electronic medical record or is not
provided to SSuN .
252
F1_GISP_GC_Ever
Has the patient ever (lifetime) been diagnosed with GC?
1= Yes
2= No
9= Not captured
Null values are allowed for (1) non-GISP patients or (2) GISP patients when
the information is collected but unavailable for patient record. A response of
9 indicates the information is not captured or collected by the facility or is
not provided to SSuN.
Facility Component – Diagnosis Records
253
F2_PatientID
Unique patient identification number assigned by site
Will be a secondary key for merging laboratory and case data; should
correspond to F1_Visdate. This data element MUST NOT be ‘null’ or contain
missing values.
254
F2_Eventid
255
F2_Visdate
Unique visit identification
Will be a secondary key for merging laboratory and case data; should
correspond to F1_Visdate. This data element MUST NOT be ‘null’ or contain
missing values.
Date of clinic visit
Will be a secondary key for merging laboratory and case data; should
correspond to F1_Visdate. This data element MUST NOT be ‘null’ or contain
missing values.
256
F2_DXCODE
Diagnosis Code
SY01=Syphilis, primary
SY02=Syphilis, secondary
SY03=Syphilis, early latent
SY04=Syphilis, late latent/Unknown
SY05=Syphilis, neurosyphilis
SY06=Syphilis, unspecified/other
GC01=Gonorrhea
CT01=Chlamydia
GW01=Genital Warts
HI01=HIV/AIDS
BV01=Bacterial vaginosis (BV)
TR01=Trichomoniasis
GH01=Genital Herpes
NU01=Nongonococcal Urethritis (NGU)
MC01=Muco-purulent cervicitis (MPC)
PI01=Pelvic Inflammatory Disease (PID)
EP01=Epididymitis
CC01=Chancroid
LV01=Lymphogranuloma venereum (LGV)
GI01=Granuloma Inguinale
CD01=Candidiasis
SC01=Scabies
PD01=Pediculosis
CS01=Contact to STD
PG01=Pregnancy
NE01=Normal exam/diagnosis
OT01=Other
Form Approved
OMB No. 0920-1072
Expiration Date ##/##/20##
SSuN Protocol (V10.0)
Null values allowed if information is collected by the facility but unknown for
this record.
Facility Component – Laboratory Records
257
F3_PatientID
Unique patient identification number assigned by site
Will be a secondary key for merging laboratory and case data; should
correspond to F1_Visdate. This data element MUST NOT be ‘null’ or contain
missing values.
258
F3_Eventid
Unique visit identification
Will be a secondary key for merging laboratory and case data; should
correspond to F1_Visdate. This data element MUST NOT be ‘null’ or contain
missing values.
259
F3_Visdate
Date of clinic visit
Will be a secondary key for merging laboratory and case data; should
correspond to F1_Visdate. This data element MUST NOT be ‘null’ or contain
missing values.
260
F3_Condtested
What condition was the patient tested for?
2 = Gonorrhea
3 = Chlamydia
6 = HIV/AIDS
20 = Pregnancy
Although a null value is allowed, sites should make every attempt to make
sure the value is not a null value. A record for a lab condition not included in
the list above, should not be submitted.
261
F3_Test_Type
What type of test was used?
1= Culture
2= Nucleic acid amplification test (NAAT)
3= Non-amplified nucleic acid test/DNA probe
4= Gram stain
10= HIV Nucleic acid test (NAT)
11= rapid HIV-1 or HIV-1/2 antibody (Ab) test
12= HIV-1 Immunoassay (IA)
13= HIV-1/2 IA
14= HIV-1/2 Ag/Ab IA
15= HIV-1 WB
16= HIV-1 IFA
17= HIV-1/HIV-2 differentiation IA
18= pooled RNA
40= Pregnancy
88= Other
99=Not captured
Although a null value is allowed, sites should make every attempt to make
sure the value is not a null value.
262
F3_Qualres
What was the qualitative test result?
0 = Negative
1 = Positive
2 = Nonreactive
3 = Reactive
4 = Indeterminate
5= Weakly Reactive
6 = QNS/Contaminated/Unsaturated
8 = Other/pending
9=Not captured
Although a null value is allowed, sites should make every attempt to make
sure the value is not a null value.
263
F3_Anatsite
What anatomic site was tested?
1 = Urethral
2 = Vaginal/cervical
3 = Urine
4 = Rectal
5 = Pharynx
6 = Blood
8 = Other
9= Not captured
Form Approved
OMB No. 0920-1072
Expiration Date ##/##/20##
SSuN Protocol (V10.0)
Although a null value is allowed, sites should make every attempt to make
sure the value is not a null value.
Facility Component – Treatment Records
264
F4_PatientID
Unique patient identification number assigned by site
Will be a secondary key for merging treatment and case data; should
correspond to F1_PatientID. This data element MUST NOT be ‘null’ or contain
missing values.
265
F4_Eventid
Unique visit identification
Will be a secondary key for merging treatment and case data; should
correspond to F1_EventID. This data element MUST NOT be ‘null’ or contain
missing values
266
F4_Visdate
Date of clinic visit
Will be a secondary key for merging treatment and case data; should
267
F4_Medication
What medication was prescribed to the patient (brand name)?
10= Amoxicillin (Amoxil, Polymox, Trimox, Wymox)
11= Ampicillin (Omnipen, Polycillin, Polycillin-N, Principen, Totacillin)
20= Azithromycin (Zithromax)
21= Erythromycin base
22= Clindamycin (Cleocin)
23= Gentamicin (Garamycin, G-Mycin, Jenamicin)
30= Cefixime (Suprax)
31= Ceftizoxime (Cefizox)
32= Cefotaxime (Claforan)
33= Cefoxitin (Mefoxin)
34= Cefpodoxime (Vantin)
35= Ceftibuten (Cedax)
36= Cefdinir (omnicef)
37= Ceftriaxone (Rocephin)
38= Cefuroxime (Ceftin, Kefurox, Zinacef, Zinnat)
40= Ciprofloxacin (Cipro, Cipro XR, Ciprobay, Ciproxin)
41= Levofloxacin (Cravit, Levaquin)
42= Moxifloxacin (Avelox, Vigamox)
43= Ofloxacin (Floxin, Oxaldin, Tarivid)
44= Gemifloxacin (Factive)
50= Doxycycline (Doryx, Vibramycin)
60= Metronidazole (Flagyl, Helidac, Metizol, Metric 21, Neo-Metric, Noritate, Novonidazol)
61= Tinidazole (Tindamax)
70= Truvada (Tenofovir/emtricitabine)
88= Other
Although a null value is allowed, sites should make every attempt to make
sure the value is not a null value.
268
F4_Medication
If the patient received a medication other than what is listed above as
indicated by response option #88, please provide name of other medication
(Free text description of other medication)
269
F4_Dosage
What was the dosage of the medication prescribed?
1= 100mg
2= 125mg
3= 150mg
4= 200mg
5= 240mg
6= 250mg
7= 300mg
8= 320mg
9= 400mg
10= 500mg
11= 600mg
12= 750mg
13= 800mg
14= 1g
15= 2g
88= Other
99= Not captured
A response of 9 indicates the information is not captured or collected by the
facility or is not provided to SSuN. Null value allowed if dosage is unknown
or missing.
Form Approved
OMB No. 0920-1072
Expiration Date ##/##/20##
SSuN Protocol (V10.0)
270
F4_Number_doses
Total number of doses prescribed?
Null value allowed if (1) number of total doses is unknown or missing or (2)
the information is not captured or collected by the facility or is not provided
to SSuN.
271
F4_Dose_Freq
What is the frequency of doses?
1=one single dose
2= twice day
3= three times a day
4= four times a day
8= other
9= Not captured
A response of 9 indicates the information is not captured or collected by the
facility or is not provided to SSuN. Null value allowed if frequency of doses is
unknown or missing.
272
F4_Duration
What duration was the medication prescribed for?
1= 1 day
2= 3 days
3= 5 days
4= 7 days
5= 10 days
6= 14 days
8= Other
9= Not captured
A response of 9 indicates the information is not captured or collected by the
facility or is not provided to SSuN. Null value allowed if duration of
medication is unknown or missing.
Facility Component – Provider Metadata File (Annual)
273
F5_Facility_ID
274
F5_SiteID
Unique facility identifier
This ID should be supplied by the site and is a unique facility identifier from
underlying surveillance systems or may be generated specifically for SSuN.
Regardless of source, this ID must be unique and allow for longitudinal
tracking of the facility. This data element MUST NOT be ‘null’ or contain
missing values.
Unique site code
BA=Baltimore
CA=California
FL=Florida
MA=Massachusetts
MN=Minnesota
MC=Multnomah county
NY=New York City
PH=Philadelphia
SF=San Francisco
WA= Washington
VA=Virginia (Cycle II)
AL=Alabama (Cycle II)
CO=Colorado (Cycle II)
CH=Chicago (Cycle II)
This data element MUST NOT be ‘null’ or contain missing values.
275
F5_Facility_name
What is the name of the facility?
276
F5_Facility_type
What is the facility type?
1= STD clinic
2=FP/RH
88= Other
277
F5_FQHC
Is this facility a FQHC?
1= Yes
2= No
278
F5_Title_X
Is this facility a Title X clinic?
1= Yes
2= No
Form Approved
OMB No. 0920-1072
Expiration Date ##/##/20##
SSuN Protocol (V10.0)
279
F5_CHC
Is this facility a Community Healthcare Center?
1= Yes
2= No
280
F5_School_based
Is this facility a school-based facility?
1=Yes
2=No
281
F5_Facility_Address
What is the physical street address of the facility?
282
F5_Facility_City
In what city is the facility located?
FIPS code, example: 3290 (City of SF)
283
F5_Facility_State
In what state is the facility located?
FIPS code
284
F5_Facility_Zip
Zip code for the facility (9-digit ZIP code of facility)
285
F5_Point_contact
Point of contact at facility
286
F5_EPT
Does the facility have written policies governing EPT?
1= Yes
2= No
3= facility does not employ EPT
287
F5_HPV_vaccine
Does the facility have written policies governing HPV vaccination?
2= No
3= facility does not provide HPV vaccination
288
F5_HIV_algorithm
Does the facility have written policies governing HIV testing?
1= Yes
2= No
3= facility does not provide HIV testing
289
F5_Screening_CT
Does the facility have written policies governing chlamydia screening?
1= Yes
2= No
3= facility does not provide CT testing
290
F5_Screening_GC
Does the facility have written policies governing gonorrhea screening?
1= Yes
2= No
3= facility does not provide GC testing
291
F5_Billing
Does the facility bill for STD services?
1= Yes
2 = No
3= Other
292
F5_Medical_record
Type of medical record system?
1= paper-based
2= electronic
3=combination
9= not sure
293
F5_Insurance
Is the facility in an insurance network?
1=Yes
2=No
Variable Name
Question
Response Coding
NS1_NEUROOCULARDX
Has a doctor or other medical person recently told you that you had
neurosyphilis, or syphilis affecting your brain, eyes, or ears?
What types of providers did the patient encounter for these symptoms?
1 = Yes, 2 = No, 9 =
Unknown
a=HIV care provider,
b=Primary care,
c=Ophthalmology,
d=a&b, e= b&c, f= a&c,
g=a,b&c
Neuro/Ocular Syphilis Supplement
Variable number
1
1.1
NEW
NS1_PROVTYPES
Form Approved
OMB No. 0920-1072
Expiration Date ##/##/20##
SSuN Protocol (V10.0)
2
NS1_DXLOC
If yes (NS1_NEUROOCULARDX = 1), where was this diagnosis made?
3
4
5
6
NS1_DXLOCOTHER_TEXT
NS1_HEARINGCHANGE
NS1_HEARINGLOSS
NS1_TINNITUS
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
NS1_HEADACHES
NS1_ALTMENSTAT
NS1_STROKE
NS1_OTHERNEUROSYMP
NS1_OTHERNEUROSYMP_TEXT
NS1_EYEPAIN
NS1_BLURRYVISION
NS1_REDEYE
NS1_VISIONCHANGES
NS1_FLASHLIGHTS
NS1_FLOATERS
NS1_VISIONLOSS
NS1_OTHEROCULARSYMP
NS1_OTHEROCULARSYMP_TEXT
NS1_LUMBPUNC
22
NS1_LUMBPUNC_MM
23
NS1_LUMBPUNC_DD
24
NS1_LUMBPUNC_YYYY
25
NS2_CHANGEHEARINGRESOLV
If NS1_DXLOC = 6 include text description
Have you experienced a change in hearing in the past 60 days?
Have you experienced hearing loss in the past 60 days?
Have you experienced ringing or buzzing in your ears (tinnitus) in the past 60
days?
Have you experienced headaches in the past 60 days?
Have you experienced an altered mental status in the past 60 days?
Have you experienced stroke-like symptoms in the past 60 days?
Have you experienced other neurological symptoms in the past 60 days?
If NS1_OTHERNEUROSYMP = 1 then include text description
Have you experienced eye pain in the past 60 days?
Have you experienced blurry vision in the past 60 days?
Have you experienced red eye in the past 60 days?
Have you experienced vision changes in the past 60 days?
Have you experienced any flashing lights in the past 60 days?
Have you experienced any floaters in the past 60 days?
Have you experienced vision loss in the past 60 days?
Have you experienced any other ocular symptoms in the past 60 days?
If NS1_OTHEROCULARSYMP = 1 include text description
As part of your care for syphilis, did you receive a spinal tap or lumbar
puncture?
If you received a spinal tap or lumbar puncture (NS1_LUMBPUNC = 1), what
was the month of the date?
If you received a spinal tap or lumbar puncture (NS1_LUMBPUNC = 1), what
was the day of the date?
If you received a spinal tap or lumbar puncture (NS1_LUMBPUNC = 1), what
was the year of the date?
Has your change in hearing resolved?
26
NS2_HEARINGLOSSRESOLV
Has your hearing loss resolved?
27
NS2_TINNITUSRESOLV
Has the buzzing or ringing in your ears (tinnitus) resolved?
28
NS2_HEADACHESRESOLV
Have your headaches resolved?
1 = STD Clinic, 2 = HIV
Care Facility, 3 = Eye
clinic, 4 = Emergency
room, 5 = Primary Care
Clinic, 6 = Other (please
describe), 9 = Unknown
Text
1 = Yes, 2 = No
1 = Yes, 2 = No
1 = Yes, 2 = No
1 = Yes, 2 = No
1 = Yes, 2 = No
1 = Yes, 2 = No
1 = Yes, 2 = No
Text
1 = Yes, 2 = No
1 = Yes, 2 = No
1 = Yes, 2 = No
1 = Yes, 2 = No
1 = Yes, 2 = No
1 = Yes, 2 = No
1 = Yes, 2 = No
1 = Yes, 2 = No
Text
1 = Yes, 2 = No, 9 =
Unknown
MM
DD
YYYY
1 = Never experienced
this symptom, 2 = Yes,
100 % resolved 3 = Yes,
mostly resolved, 4 = Yes,
but only resolved
somewhat, 5 = No,
symptom has persisted or
worsened
1 = Never experienced
this symptom, 2 = Yes,
100 % resolved 3 = Yes,
mostly resolved, 4 = Yes,
but only resolved
somewhat, 5 = No,
symptom has persisted or
worsened
1 = Never experienced
this symptom, 2 = Yes,
100 % resolved 3 = Yes,
mostly resolved, 4 = Yes,
but only resolved
somewhat, 5 = No,
symptom has persisted or
worsened
1 = Never experienced
this symptom, 2 = Yes,
100 % resolved 3 = Yes,
mostly resolved, 4 = Yes,
but only resolved
somewhat, 5 = No,
symptom has persisted or
worsened
Form Approved
OMB No. 0920-1072
Expiration Date ##/##/20##
SSuN Protocol (V10.0)
29
NS2_ALTMENTALRESOLV
Has your altered mental status resolved?
30
NS2_EYEPAINRESOLV
Has your eye pain resolved?
31
NS2_REDEYERESOLV
Has your red eye resolved?
32
NS2_BLURRYVISIONRESOLV
Has your blurry vision resolved?
33
NS2_VISIONCHANGESRESOLV
Have your vision changes resolved?
34
NS2_VISIONLOSSRESOLV
Has your vision loss resolved?
35
NS2_FLOATERSRESOLV
Have your floaters resolved?
36
NS2_FLASHLIGHTSRESOLV
Have the flashing lights resolved?
37
NS2_OTHERRESOLV_1
Were there any other symptoms not listed that have since resolved?
1 = Never experienced
this symptom, 2 = Yes,
100 % resolved 3 = Yes,
mostly resolved, 4 = Yes,
but only resolved
somewhat, 5 = No,
symptom has persisted or
worsened
1 = Never experienced
this symptom, 2 = Yes,
100 % resolved 3 = Yes,
mostly resolved, 4 = Yes,
but only resolved
somewhat, 5 = No,
symptom has persisted or
worsened
1 = Never experienced
this symptom, 2 = Yes,
100 % resolved 3 = Yes,
mostly resolved, 4 = Yes,
but only resolved
somewhat, 5 = No,
symptom has persisted or
worsened
1 = Never experienced
this symptom, 2 = Yes,
100 % resolved 3 = Yes,
mostly resolved, 4 = Yes,
but only resolved
somewhat, 5 = No,
symptom has persisted or
worsened
1 = Never experienced
this symptom, 2 = Yes,
100 % resolved 3 = Yes,
mostly resolved, 4 = Yes,
but only resolved
somewhat, 5 = No,
symptom has persisted or
worsened
1 = Never experienced
this symptom, 2 = Yes,
100 % resolved 3 = Yes,
mostly resolved, 4 = Yes,
but only resolved
somewhat, 5 = No,
symptom has persisted or
worsened
1 = Never experienced
this symptom, 2 = Yes,
100 % resolved 3 = Yes,
mostly resolved, 4 = Yes,
but only resolved
somewhat, 5 = No,
symptom has persisted or
worsened
1 = Never experienced
this symptom, 2 = Yes,
100 % resolved 3 = Yes,
mostly resolved, 4 = Yes,
but only resolved
somewhat, 5 = No,
symptom has persisted or
worsened
1 = Never experienced
this symptom, 2 = Yes,
100 % resolved 3 = Yes,
mostly resolved, 4 = Yes,
but only resolved
somewhat, 5 = No,
symptom has persisted or
worsened
Form Approved
OMB No. 0920-1072
Expiration Date ##/##/20##
SSuN Protocol (V10.0)
38
39
NS2_OTHERRESOLV_1_TEXT
NS2_OTHERRESOLV_2
If NS2_OTHERRESOLV_1 ≠ 1 include text description
Were there any other symptoms not listed that have since resolved?
40
41
NS2_OTHERRESOLV_2_TEXT
NS2_SYMPADD
If NS2_OTHERRESOLV_2 ≠ 1 include text description
Did you develop any additional symptoms after treatment?
42
43
44
45
46
47
NS2_SYMPADDHEARINGCHANGE
NS2_SYMPADDHEARINGLOSS
NS2_SYMPADDHEADACHES
NS2_SYMPADDSTROKE
NS2_SYMPADDALMENSTAT
NS2_SYMPADDTINNITUS
Did you experience a change in hearing following treatment?
Did you experience a loss in hearing following treatment?
Did you experience headaches following treatment?
Did you experience any stroke-like symptoms following treatment?
Did you experience an altered mental status following treatment?
Did you experience a ringing or buzzing in ears (tinnitus) following treatment?
48
49
50
51
52
53
54
55
56
57
NS2_SYMPADDEYEPAIN
NS2_SYMPADDREDEYE
NS2_SYMPADDBLURRYVISION
NS2_SYMPADDVISIONCHANGES
NS2_SYMPADDFLOATERS
NS2_SYMPADDVISIONLOSS
NS2_SYMPADDFLASHINGLIGHTS
NS2_SYMPADDOTHER
NS2_SYMPADDOTHER_TEXT
NS3_ROUTINE
58
NS3_ROUTINEFORM
59
NS3_NEURODX
Did you experience any eye pain following treatment?
Did you experience any red eye following treatment?
Did you experience any blurry vision following treatment?
Did you experience any vision changes following treatment?
Did you experience any floaters following treatment?
Did you experience any vision loss following treatment?
Did you experience any flashing lights following treatment?
Did you experience any other symptoms following treatment?
If NS2_SYMPADDOTHER = 1 (“Yes”) include text description
Do you routinely screen your patients with syphilis for symptoms of ocular,
otic, or neurosyphilis?
If patients with syphilis are routinely screened for ocular, otic, or neurosyphilis
do you have a form that you use for screening?
Did this patient receive a clinical diagnosis of neurosyphilis?
60
NS3_OCULARDX
Did this patient receive a clinical diagnosis of ocular syphilis?
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
NS3_HEARINGCHANGE
NS3_HEARINGLOSS
NS3_HEADACHES
NS3_STROKE
NS3_ALTMENSTAT
NS3_TINNITUS
NS3_OTHERNEUROSYMP
NS3_OTHERNEUROSYMP_TEXT
NS3_EYEPAIN
NS3_REDEYE
NS3_VISIONLOSS
NS3_VISIONCHANGES
NS3_FLASHINGLIGHTS
NS3_BLURRYVISION
NS3_FLOATERS
NS3_OTHEROCULARSYMP
77
78
NS3_OTHEROCULARSYMP_TEXT
NS3_OPTHALEXAM
Did the patient present with a change in hearing?
Did the patient present with hearing loss?
Did the patient present with headaches?
Did the patient present with stroke-like symptoms?
Did the patient present with an altered mental status?
Did the patient present with buzzing or ringing in ears (tinnitus)?
Did the patient present with other symptoms consistent with neurosyphilis?
If NS3_OTHERNEUROSYMP = 1 (“Yes”) include text description
Did the patient present with eye pain?
Did the patient present with red eye?
Did the patient present with vision loss?
Did the patient present with vision changes?
Did the patient present with symptoms of flashing lights?
Did the patient present with blurry vision?
Did the patient present with symptoms of floaters?
Did the patient present with any other symptoms consistent with ocular
syphilis?
If NS3_OTHEROCULARSYMP = 1 (“Yes”) include text description
Did the patient have an ophthalmologic exam?
79
80
81
82
83
84
85
86
NS3_OPTHALEXAMUVEITIS
NS3_OPTHALEXAMSCLERITIS
NS3_OPTHALEXAMRETINITIS
NS3_OPTHALEXAMNEURITIS
NS3_OPTHALEXAMRETDETACH
NS3_OTHEROPTHALEXAM
NS3_OTHEROPTHALEXAM_TEXT
NS3_LUMBPUNC
Was uveitis one of the ophthalmologic exam findings?
Was Scleritis/keratitis one of the ophthalmologic exam findings?
Was Retinitis/Chorioretinitis one of the ophthalmologic exam findings?
Was Optic Neuritis one of the ophthalmologic exam findings?
Was Retinal Detachment one of the ophthalmologic exam findings?
Were there any other ophthalmologic exam findings?
If NS3_OTHEROPTHALEXAM = 1 (“Yes”) include text description
Was a spinal tap or lumbar puncture performed?
87
NS3_LUMBPUNC_MM
88
NS3_LUMBPUNC_DD
If a spinal tap or lumbar puncture was done, during which month was this
performed?
If a spinal tap or lumbar puncture was done, on which day was this performed? DD
89
NS3_LUMBPUNC_YYYY
If a spinal tap or lumbar puncture was done, during which year was this
performed?
Text
1 = Never experienced
this symptom, 2 = Yes,
100 % resolved 3 = Yes,
mostly resolved, 4 = Yes,
but only resolved
somewhat, 5 = No,
symptom has persisted or
worsened
Text
1 = Yes, 2 = No, 9 =
Unknown
1 = Yes, 2 = No
1 = Yes, 2 = No
1 = Yes, 2 = No
1 = Yes, 2 = No
1 = Yes, 2 = No
1 = Yes, 2 = No
1 = Yes, 2 = No
1 = Yes, 2 = No
1 = Yes, 2 = No
1 = Yes, 2 = No
1 = Yes, 2 = No
1 = Yes, 2 = No
1 = Yes, 2 = No
1 = Yes, 2 = No
Text
1 = Yes, 2 = No, 9 =
Unknown
1 = Yes, 2 = No, 9 =
Unknown
1 = Yes, 2 = No, 9 =
Unknown
1 = Yes, 2 = No, 9 =
Unknown
1 = Yes, 2 = No
1 = Yes, 2 = No
1 = Yes, 2 = No
1 = Yes, 2 = No
1 = Yes, 2 = No
1 = Yes, 2 = No
1 = Yes, 2 = No
Text
1 = Yes, 2 = No
1 = Yes, 2 = No
1 = Yes, 2 = No
1 = Yes, 2 = No
1 = Yes, 2 = No
1 = Yes, 2 = No
1 = Yes, 2 = No
1 = Yes, 2 = No
Text
1 = Yes, 2 = No, 9 =
Unknown
1 = Yes, 2 = No
1 = Yes, 2 = No
1 = Yes, 2 = No
1 = Yes, 2 = No
1 = Yes, 2 = No
1 = Yes, 2 = No
Text
4 = Yes, 2 = No, 9 =
Unknown
MM
YYYY
Form Approved
OMB No. 0920-1072
Expiration Date ##/##/20##
SSuN Protocol (V10.0)
90
NS3_LUMBPUNCROUTINE
91
92
93
94
95
96
NS3_LUMBPUNCSYMPTOMS
NS3_LUMBPUNCHIVSTAT
NS3_LUMBPUNCUNKNOWN
NS3_OTHERLUMBPUNC
NS3_OTHERLUMBPUNC_TEXT
NS3_CSFVDRL
Was the lumbar puncture performed because it is a routine procedure at this
facility?
Was the lumbar puncture performed based on patient symptoms?
Was the lumbar puncture performed based on the patient’s HIV status?
Was the lumbar puncture performed for an unknown reason?
Was there another reason the lumbar puncture was performed?
If NS3_OTHERLUMBPUNC = 1 (“Yes”) include text description
CSF VDRL result
97
NS3_CSFFTA_ABS
CSF FTA-ABS result
98
99
100
101
NS3_CSFWBC
NS3_CSFTOTPROTEIN
NS3_CSFGLUCOSE
NS3_BENZPENG_A
102
NS3_BENZPENG_B
103
NS3_BENZPENG_C
104
NS3_BENZPENG_D
105
NS3_AQCRYSTPENG_A
106
NS3_AQCRYSTPENG_B
107
108
109
110
111
NS3_DOXYCYC_A
NS3_DOXYCYC_B
NS3_TETRACYC_A
NS3_TETRACYC_B
NS3_PROCPENPROB
112
NS3_PROCPEN
113
114
115
116
NS3_CEFTRIAX_A
NS3_CEFTRIAX_B
NS3_OTHERTX
NS3_SYPHTX_TEXT
WBC total
CSF total protein
CSF glucose
Was the patient prescribed Benzathine penicillin G, 2.4 million units IM single
dose?
Was the patient prescribed Benzathine penicillin G, 2,4 million units in 3 doses
at 1 week intervals (max total 7.2 million units)
Was the patient prescribed Benzathine penicillin G, 50000 units/kg IM, single
dose (max total 2.4 million units)
Was the patient prescribed Benzathine penicillin G, 50000 units/kg IM, 3 doses,
1 weel intervals (max total 7.2 million units)
Was the patient prescribed Aqueous crystalline penicillin G IV, 18-24 million
units/day, administered as 3-4 million units IV every 4 hrs, for 10-14 days?
Was the patient prescribed Aqueous crystalline penicillin G IV, 18-24 million
units/day, administered as continuous infusion, for 10-14 days?
Was the patient prescribed Doxycycline, 100 mg 2x/day for 14 days?
Was the patient prescribed Doxycycline, 100 mg 2x/day for 28 days?
Was the patient prescribed Tetracycline, 500 mg orally 4x/day for 14 days?
Was the patient prescribed Tetracycline, 500 mg orally 4x/day for 28 days?
Was the patient prescribed Procaine penicillin G 2.4 million units IM 1x daily,
PLUS probenecid (500 mg, 4 times a day, borh for 10-14 days?
Was the patient prescribed Procaine penicillin G 2.4 million units IM 1x daily for
10-14 days without probenecid?
Was the patient prescribed Ceftriaxone 250 mg IM in a single dose?
Was the patient prescribed Ceftriaxone 1 g IM in a single dose?
Was the patient prescribed any other treatment?
If NS3_OTHERTX = 1 (“Yes”) include text description
1 = Yes, 2 = No
1 = Yes, 2 = No
1 = Yes, 2 = No
1 = Yes, 2 = No
1 = Yes, 2 = No
Text
1 = Reactive, 2 = Nonreactive, 3 = Not done
1 = Reactive, 2 = Nonreactive, 3 = Not done
# (WBC/mm3)
# (mg/100 ml)
# (mg/100 ml)
1 = Yes, 2 = No
2 = Yes, 2 = No
3 = Yes, 2 = No
4 = Yes, 2 = No
1 = Yes, 2 = No
1 = Yes, 2 = No
1 = Yes, 2 = No
1 = Yes, 2 = No
2 = Yes, 2 = No
3 = Yes, 2 = No
1 = Yes, 2 = No
1 = Yes, 2 = No
1 = Yes, 2 = No
1 = Yes, 2 = No
1 = Yes, 2 = No
Text
| File Type | application/pdf |
| File Title | DataElementTable_V10.2.xlsx |
| Author | gge3 |
| File Modified | 2018-07-26 |
| File Created | 2018-07-26 |