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Performance Measurement for STD Prevention (NCHHSTP, 2020-2022)

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Performance Measurement for STD Prevention (NCHHSTP, 2020-2022)
Patel, Vrajesh
Calc
2020-02-24
2026-09-06
complete

Extracted Text

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

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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

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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

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(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

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