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Performance Measurement for STD Prevention (NCHHSTP, 2020-2022)
ICR 201907-0920-007 · OMB 0920-1282 · Object 99033101.
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| File Type | application/vnd.openxmlformats-officedocument.spreadsheetml.sheet |
|---|---|
| File Title | Performance Measurement for STD Prevention (NCHHSTP, 2020-2022) |
| Author | Patel, Vrajesh |
| Last Modified By | Calc |
| File Modified | 2020-02-24 |
| File Created | 2026-09-06 |
| Conversion State | complete |
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STD PCHD Performance Measurement Year 1 Form Approved OMB No. 0920-1282 Expiration Date: 1/31/2023 Project Area: [Select Project Area] Period of Performance: 1/1/2019 - 12/31/2019 Submission Date: If other reporting period, or if varies by [Free Text] performance measure, describe: Other comments related to this submission [Free Text] (optional): Click the navigation bar or a tab at the bottom of the workbook to jump to the corresponding worksheet. Instructions: You may use this template to prepare a STD PCHD Performance Measures for DSTDP. Please refer to the supplemental guidance document for more information. Complete each tab in this workbook, except for those labeled "optional." Applicants will complete and submit performance measures each year, depending on approval from OMB. If you need technical support at any time, please send an email with a detailed description of your need to the following address: [email protected] Notes on Data Entry: All light yellow cells are available for user input. White cells are auto-calculated based on information provided in the yellow cells. Drop-down menus are included in all worksheets, and should be identifiable through a downward arrow that appears when you select it. The core performance measures in each worksheet are bolded. Measures that are auto-calcuated but not considered core performance measures are italicized (not bolded). Saving and Submitting Your Work: Click "File" from the ribbon above and then "Save" from the menu. If this is your first time saving this document, you will be prompted to choose a location for where this file will be saved. Please save this file as "[ProjectAreaName]_Performance.Measures.2019_yy-mm-dd" and as an .xlsm version. (Note: you will see a warning message reminding you that if you change the format of the document, you may lose some of the functionality. Click "Ok" and save the file in your preferred location.) Click "File" from the ribbon above and then "Save As" from the menu or use the button below. Choose the .xls or .xlsx file type from the "Save as type" drop-down menu. You will see a warning sign that says "The following features cannot be saved in macro-free workbooks: VB project". Click "Yes" to save the file as a .xls or .xlsx file type. You will still be able to edit light yellow cells, but a few features from this workbook will no longer be available. To submit this document, attach the file ending in .xls or .xlsx as a Grant Note in GrantSolutions. Relevant Links: To access the series of Technical Assistance Notes for the PS19-1901 STD PCHD strategies, click here: PS19-1901 STD PCHD Technical Assistance Notes To find general information on using Microsoft Excel, click here: Microsoft Excel Basics Reporting Burden This information is collected under the authority of the Public Health Service Act, Section 301, "Research and Investigation," (42 U.S.C. 241); and Sections 304, 306 and 308(d) which discuss authority to maintain data and provide assurances of confidentiality for health research and related activities (42 U.S.C. 242 b, k, and m(d)). This information is also being collected in conjunction with the provisions of the Government Paperwork Elimination Act and the Paperwork Reduction Act (PRA). This information will only be used by the Centers for Disease Control and Prevention (CDC) staff to monitor recipient’s progress under cooperative agreement PS19-1901 STD PCHD. Public reporting burden of this collection of information is estimated to average 30 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; Attn: OMB-PRA (0920-1282) Surveillance Line No. Enhanced GC surveillance a_1 Did your project area complete follow-up of any GC cases for any enhanced GC surveillance purposes (Strategy 2b) in the reporting period? a_2 If yes (a_1), what geographic area(s) were included in the enhanced GC surveillance activities? a_3 Out of 12 months in the reporting period, what dates did your project area conduct enhanced GC surveillance? a_4 Total # of GC cases that were reported in that time period (a_3) and in that geographic area (a_2) Among those (a_4), # of GC cases that were randomly selected for enhanced surveillance Among those (a_5), # that received provider and/or patient follow-up for enhanced surveillance Among GC cases sampled for enhanced surveillance followup, % that received provider and/or patient follow-up a_5 a_6 a_7 a_8 Low or poor data quality? a_9 Any data limitations, including reasons unable to report Data Fields drop down menu text field #DIV/0! autocalculated drop down menu text field a_10 a_11 a_12 a_13 a_14 Pregnancy Ascertainment Total # of female syphilis cases (all stages) Total # of female syphilis cases (all stages) with pregnancy status documented as "Yes, pregnant" Total # of female syphilis cases (all stages) with pregnancy status documented as "No, not pregnant" Total # of female syphilis cases (all stages) with pregnancy status documented as "Unknown" or “Missing” a_18 Proportion of female syphilis cases (all stages) that had pregnancy status documented as "Yes, pregnant" or "No, not pregnant" Is your surveillance and/or case management system able to document when pregnancy status was obtained? If yes (a_15): Total # of female syphilis cases (all stages) with pregnancy status documented as "Yes, pregnant" or "No, not pregnant" within 14 days of specimen collection Among all female syphilis cases (all stages), % with pregnancy status documented as “Yes, pregnant” or “No, not pregnant” within 14 days of specimen collection Low or poor data quality? a_19 Any data limitations, including reasons unable to report a_15 a_16 a_17 #DIV/0! autocalculated drop down menu #DIV/0! autocalculated drop down menu text field Congenital Syphilis Line No. Potential cases averted Total # of females with syphilis (all stages) in the project area b_1 in the reporting period Total # of pregnant females with syphilis (all stages) b_2 b_3 % of total female syphilis cases that were pregnant Data Fields #DIV/0! auto-calculated b_4 b_5 Total # of reported congenital syphilis cases and stillbirths Total # of potential congenital syphilis cases averted 0.00 auto-calculated b_6 Among all potential congenital syphilis cases, % averted #DIV/0! auto-calculated b_7 Low or poor data quality? drop down menu b_8 Any data limitations, including reasons unable to report text field Outbreak response Line No. Disease Investigation and Intervention Activation of STD outbreak response plan Total # of times that the outbreak plan was initiated for c_1 syphilis by the project area in the reporting period Total # of times that the outbreak plan was initiated for GC in c_2 the reporting period Total # of times that the outbreak plan was initiated for c_3 another STD in the reporting period Total # of times that the outbreak plan was initiated for an c_4 STD Staff assignments to assist other outbreaks Total # of the STD program staff who were given temporary, c_5 formal assignments to assist with outbreaks with HIV, Hepatitis, or TB, during the reporting period Total # of STD program staff who were given temporary, c_6 formal assignments to assist with outbreaks with other conditions (not STD, HIV, Hepatitis, TB) during the reporting period c_7 Total # of STD staff deployed for non-STD outbreaks Total # of outbreak responses (HIV, Hepatitis, TB, or other c_8 conditions) for which those staff were formally assigned to assist. Data quality c_9 Low or poor data quality? c_10 Any data limitations, including reasons unable to report Data Fields 0 autocalculated 0 autocalculated drop down menu text field Line No. d_1 d_2 d_3 d_4 d_5 d_6 d_7 d_8 d_9 d_10 d_11 d_12 d_13 d_14 d_15 d_16 d_17 d_18 d_19 Key Populations: Total # of early syphilis cases by the project area in the reporting period Total # of cases initiated Total # of cases interviewed Interview Rate Total # of contacts (partners) initiated for partner services Contact Index Total # of contacts examined (tested) within 30 days before or after the index patient’s initial specimen collection (Dispo A, B, C, D, E, F, Z) New Exam Rate Total # of contacts previously treated (Dispo E) within 30 days before or after the index patient's initial specimen collection Total # of contacts preventively treated (Dispo A) within 30 days before or after the index patient's initial specimen collection Total # of contacts preventively treated (Dispo Z) within 30 days before or after the index patient's initial specimen collection Early Syphilis Cases: Disease Investigation and Intervention Pregnant females under Other females under Men with only female Men with male partners age 45 age 45 partners (MSW) (MSM and MSMW) 0 0 0 #DIV/0! #DIV/0! #DIV/0! #DIV/0! auto-calculated 0 #DIV/0! #DIV/0! #DIV/0! #DIV/0! auto-calculated 0 #DIV/0! #DIV/0! #DIV/0! #DIV/0! auto-calculated 0 0 0 Total # of contacts brought to Tx for new syphilis infection (Dispo C) within 30 days after the index patient's initial specimen collection Treatment Index Total # of cases w/at least 1 contact treated for syphilis (Dispo A, C, E, Z) within 30 days before or after the index patient’s initial specimen collection Disease intervention rate Total number of contacts (partners) brought to treatment Total number of new cases of syphilis found through partner services Low or poor data quality? Any data limitations, including reasons unable to report Sum Totals (autocalculated) 0 #DIV/0! #DIV/0! #DIV/0! #DIV/0! auto-calculated 0 #DIV/0! #DIV/0! #DIV/0! #DIV/0! 0 0 0 0 0 auto-calculated 0 0 0 0 0.00 auto-calculated auto-calculated drop down menu text field Line No STD -related HIV Prevention in Disease Investigation e_1 MSM GC Cases (If any investigated) Syphilis Cases, by priority population Pregnant females under Other females under age age 45 with early syphilis 45 with early syphilis Men with only female partners (MSW) with early syphilis Men with male partners Men with male partners (MSM and MSMW) with (MSM and MSMW) with early syphilis GC cases only e_2 Total # of cases in the project area in the reporting period 0 0 0 0 prepopulated from sheets D and E e_3 Total # of cases initiated 0 0 0 0 prepopulated from sheets D and E e_4 Total # of cases interviewed 0 0 0 0 prepopulated from sheets D and E e_5 Of interviewed, # known to be living with HIV at the time of syphilis (of GC) diagnosis e_6 Of interviewed, # newly-diagnosed with HIV within 30 days of syphilis (or GC) diagnosis e_7 Of syphilis (or GC) cases newly diagnosed with HIV, # linked to HIV care within 30 days of new HIV diagnosis e_8 Of interviewed, # referred for PrEP within 30 days of syphilis (or GC) diagnosis e_9 Among interviewed, (known) HIV coinfection rate 0 #DIV/0! 0 0 #DIV/0! e_10 Among interviewed syphilis or GC cases (and not known to be HIV+), % newly-diagnosed with HIV within 30 days of syphilis (or GC) diagnosis 0 #DIV/0! #DIV/0! #DIV/0! #DIV/0! e_11 Low or poor data quality drop down menu e_12 Any data limitations, including reasons unable to report text field e_13 Among interviewed and newly diagnosed with HIV, % linked to HIV care within 30 days of new HIV diagnosis e_14 Low or poor data quality? drop down menu e_15 Any data limitations, including reasons unable to report text field e_16 Among interviewed (and not known to be HIV+), % referred for PrEP within 30 days of syphilis (or GC) diagnosis e_17 Low or poor data quality? drop down menu e_18 Any data limitations, including reasons unable to report text field #DIV/0! 0 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! Treatment Line No. Recommended Treatment for syphilis Total # of early syphilis (ES) cases in the project area in the f_1 reporting period Total # of early syphilis cases missing data on medication f_2 Total # of early syphilis cases missing data on medication AND f_3 date of treatment or date of specimen collection (unable to calculate timeliness of treatment) f_4 % of early syphilis cases missing documentation of medication f_5 f_6 f_7 f_8 % of early syphilis cases missing data to calculate timely treatment AND documentation of medication Total # of early syphilis cases documented as having been prescribed/received BPG within 14 days of date of specimen collection Among early syphilis cases, % treated by BPG within 14 days of specimen collection Low or poor data quality? f_20 Any data limitations, including reasons unable to report Recommended Treatment for Gonorrhea For this measure, is the project area reporting on all cases or a random sample of cases, based on enhanced GC surveillance? If neither, explain below in Data Notes (g_21) Total # of GC cases reported in the reporting period (Overall or in random sample) Total # of GC cases missing data on medication (among all or among random sample) Total # of GC cases missing data on medication AND date of treatment or date of specimen collection(among all or among random sample) % of GC cases missing documentation of medication (among all or among random sample) % of GC cases missing data to calculate timely treatment AND documentation of medication (among all or among random sample) Total # of GC cases with recommended medication (in 2019: dual therapy) documented (among all or among random sample) Total # of GC cases with recommended medication (in 2019: dual therapy) documented as having been prescribed/received within 14 days of date of specimen collection (among all or among random sample) Among all GC cases, % with recommended medication documented, per CDC guidance (among all or among random sample) Among all GC cases, % with recommended medication documented within 14 days of the date of specimen collection, per CDC guidance (among all or among random sample) Low or poor data quality? f_21 Any data limitations, including reasons unable to report f_9 f_10 f_11 f_12 f_13 f_14 f_15 f_16 f_17 f_18 f_19 Data Fields #DIV/0! auto calculated #DIV/0! auto calculated #DIV/0! drop down menu text drop down #DIV/0! auto calculated #DIV/0! auto calculated #DIV/0! auto calculated #DIV/0! auto calculated drop down menu text Line No. sna_1 sna_2 sna_3 sna_4 sna_5 sna_6 sna_7 sna_8 sna_9 sna_10 sna_11 sna_12 sna_13 sna_14 sna_15 sna_16 sna_17 sna_18 sna_19 sna_20 sna_21 sna_22 sna_23 sna_24 sna_25 sna_28 sna_29 sna_30 sna_31 sna_32 General Description of Safety Net Assistance (SNA) Description Data Fields Approximately what % of the STD PCHD budget did the project area devote to safety net assistance in the reporting period? Adolescents/young adults Did the project area specifically focus the safety net assistance MSM towards any of the following demographic groups? (select all Pregnant women that apply) No, none of these groups were specifically focused on (though they may have benefited) They met a certain threshold for positivity for testing They met a certain threshold for STD disease morbidity or a certain STD case count or rate What were the main formal criteria used for selecting which They served under/uninsured populations providers or organizations were eligible to access the safety They served other priority populations or geographic areas in net assistance (SNA) or were funded for SNA? (select all that need of subsidized services apply) They had a track record of effective partnership with us I’m not sure/don’t know Other: (please write answer below in sna_45 text box) CT/GC urine testing/screening CT/GC extragenital testing/screening CT/GC treatment, including EPT Which STD clinical prevention services did the safety net Syphilis testing/screening assistance support? Select all that apply. Syphilis treatment Other STD clinical preventive service: (please write answer below in sna_45 text box) STD specialty care clinics Local health department clinics (general) Family planning/ reproductive health clinics Maternal and child health programs HIV prevention or care clinics Behavioral or mental health agencies, including drug treatment Which types of providers were funded directly by the project Federally-qualified health centers (FQHC) or other community health centers area for safety net assistance (SNA) or were given the opportunity to take advantage of the SNA during the reporting Correctional facilities (prison, jail, juvenile detention) period? Select all that apply. School-based, college, or university health centers Tribal or Indian Health Service health care centers Other non-profit, private health care providers or organizations (e.g., CBOs) Other private health care providers or organizations Others not listed: (please write answer below in sna_45 text box) We don’t know/ aren’t sure Often found in Contract budget line: What are the primary mechanisms through which the project all drop down menus unless noted as "text" sna_33 sna_34 sna_35 sna_36 sna_37 sna_38 sna_39 sna_40 sna_41 sna_42 sna_43 (A) Direct contracts or subgrants with health care organizations or providers for safety net assistance only (B) Direct contracts or subgrants with health care organizations or providers for various services that include safety net assistance What are the primary mechanisms through which the project (C) Direct contracts or subgrants with lab(s) (public or private) area provided the safety net assistance (SNA)? Select all that to conduct testing for certain providers apply. Often found in Supplies, Other, or Personnel: (D) Purchase of test kits or treatment/EPT, which are then distributed or allocated to certain providers by us (E) Support all/part of the salary of lab(s) staff to conduct testing for certain providers or types of tests (F) Other: (please write answer below in sna_45 text box) Yes, we added state (or local) project area funds (e.g. STD, general) Did the project area combine the STD PCHD safety net Yes, we added federal funds (e.g. HIV, Title X, HRSA) assistance with funding from other sources, to fund those Yes, we added other funding sources contracts/ subgrants (A-C), to make those purchases (D), or No, STD PCHD was the only funding we put into those support those staff (E)? Select all that apply. contracts/subgrants/purchases Don't know/ too unsure to answer (Optional) Please provide any other information you would like to add about your approach to providing SNA in the reporting period, or answers to question on this worksheet for which you selected "Other": sna_44 sna_45 sna_46 sna_47 sna_48 sna_49 sna_50 sna_51 text Often found in Contract budget line: (A) Direct contracts or subgrants with health care organizations or providers for safety net assistance only (B) Direct contracts or subgrants with health care organizations or providers for various services that include safety net assistance (C) Direct contracts or subgrants with lab(s) (public or private) For which parts of your safety net assistance do you have data to conduct testing for certain providers Often found in Supplies, Other, or Personnel: on tests conducted, test results, or treatment purchased? (D) Purchase of test kits or treatment/EPT, which are then distributed or allocated to certain providers by us (E) Support all/part of the salary of lab(s) staff to conduct testing for certain providers or types of tests (F) Other: (please write answer below in line s) We do not have any data at this time (please provide reason why not, above in sna_45 text box) If A-F is selected, please complete an "Admin_SNA_test_TX_data" worksheet for each mechanism selected. Up to 3 total. Complete 1 table per merchanism selected in Admin_SNA_overall (sna_45-sna_51) Line No. Descripton Data Fields Data Fields sna_52 Which mechanism does the following refer to? sna_53 sna_54 sna_55 sna_56 sna_57 sna_58 sna_59 sna_60 sna_61 sna_62 sna_63 sna_64 sna_65 sna_66 sna_67 sna_68 sna_69 sna_70 sna_71 sna_72 sna_73 sna_74 sna_75 sna_76 sna_77 sna_78 sna_79 sna_80 sna_81 Which of the following groups of clients does the following testing data refer to? How many tests were conducted? Total tests conducted All Males Males, 15-24 years Males, 25-44 Males, 45+ All Females Females, 15-24 years Females, 25-44 Females, 45+ Of those tests, how many were positive or reactive? Total positive or reactive tests All Males Males, 15-24 years Males, 25-44 Males, 45+ All Females Females, 15-24 Females, 25-44 Females, 45+ Positivity Total tests All Males Males, 15-24 years Males, 25-44 Males, 45+ All Females Females, 15-24 Females, 25-44 Females, 45+ Treatment medication (if any purchased with STD PCHD safety net assistance) Total medication units purchased in reporting period. Please write in units tracked by your program, e.g. "X# BIC injections" or "Y# pills" or "Z# patient TX packs." Data Fields [Select from Dropdown] Syphilis tests performed GC tests performed CT tests performed Positive Syphilis tests Positive GC tests Positive CT tests Among Syphilis tests performed #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! Among GC tests performed #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! Among CT tests performed #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! Syphilis medication GC medication CT medication If you are unable to provide the above information on the tests performed, test results, or treatment purchases attributable to STD PCHD, please explain why not: sna_82 text (Optional) Please provide any other information you would like to add about the treatment or patient testing data that you provided on the safety net assistance in the reporting period: sna_83 text USE ONLY IF MORE THAN 1 MECHANISM IS BEING REPORTED ON Complete 1 table per merchanism selected in Admin_SNA_overall (sna_45-sna_51) Line No. Descripton Data Fields Data Fields sna_52 Which mechanism does the following refer to? sna_53 sna_54 sna_55 sna_56 sna_57 sna_58 sna_59 sna_60 sna_61 sna_62 sna_63 sna_64 sna_65 sna_66 sna_67 sna_68 sna_69 sna_70 sna_71 sna_72 sna_73 sna_74 sna_75 sna_76 sna_77 sna_78 sna_79 sna_80 sna_81 Which of the following groups of clients does the following testing data refer to? How many tests were conducted? Total tests conducted All Males Males, 15-24 years Males, 25-44 Males, 45+ All Females Females, 15-24 years Females, 25-44 Females, 45+ Of those tests, how many were positive or reactive? Total positive or reactive tests All Males Males, 15-24 years Males, 25-44 Males, 45+ All Females Females, 15-24 Females, 25-44 Females, 45+ Positivity Total tests All Males Males, 15-24 years Males, 25-44 Males, 45+ All Females Females, 15-24 Females, 25-44 Females, 45+ Treatment medication (if any purchased with STD PCHD safety net assistance) Total medication units purchased in reporting period. Please write in units tracked by your program, e.g. "X# BIC injections" or "Y# pills" or "Z# patient TX packs." Data Fields [Select from Dropdown] Syphilis tests performed GC tests performed CT tests performed Positive Syphilis tests Positive GC tests Positive CT tests Among Syphilis tests performed #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! Among GC tests performed #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! Among CT tests performed #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! Syphilis medication GC medication CT medication If you are unable to provide the above information on the tests performed, test results, or treatment purchases attributable to STD PCHD, please explain why not: sna_82 text (Optional) Please provide any other information you would like to add about the treatment or patient testing data that you provided on the safety net assistance in the reporting period: sna_83 text USE ONLY IF MORE THAN 2 MECHANISMS ARE BEING REPORTED ON Complete 1 table per merchanism selected in Admin_SNA_overall (sna_45-sna_51) Line No. Descripton Data Fields Data Fields sna_52 Which mechanism does the following refer to? sna_53 sna_54 sna_55 sna_56 sna_57 sna_58 sna_59 sna_60 sna_61 sna_62 sna_63 sna_64 sna_65 sna_66 sna_67 sna_68 sna_69 sna_70 sna_71 sna_72 sna_73 sna_74 sna_75 sna_76 sna_77 sna_78 sna_79 sna_80 sna_81 Which of the following groups of clients does the following testing data refer to? How many tests were conducted? Total tests conducted All Males Males, 15-24 years Males, 25-44 Males, 45+ All Females Females, 15-24 years Females, 25-44 Females, 45+ Of those tests, how many were positive or reactive? Total positive or reactive tests All Males Males, 15-24 years Males, 25-44 Males, 45+ All Females Females, 15-24 Females, 25-44 Females, 45+ Positivity Total tests All Males Males, 15-24 years Males, 25-44 Males, 45+ All Females Females, 15-24 Females, 25-44 Females, 45+ Treatment medication (if any purchased with STD PCHD safety net assistance) Total medication units purchased in reporting period. Please write in units tracked by your program, e.g. "X# BIC injections" or "Y# pills" or "Z# patient TX packs." Data Fields [Select from Dropdown] Syphilis tests performed GC tests performed CT tests performed Positive Syphilis tests Positive GC tests Positive CT tests Among Syphilis tests performed #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! Among GC tests performed #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! Among CT tests performed #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! Syphilis medication GC medication CT medication If you are unable to provide the above information on the tests performed, test results, or treatment purchases attributable to STD PCHD, please explain why not: sna_82 text (Optional) Please provide any other information you would like to add about the treatment or patient testing data that you provided on the safety net assistance in the reporting period: sna_83 text