Form 0920-0995 STD Tx Guidelines Short Long-Term Evaluation wordversion

National Network of Sexually Transmitted Disease Clinical Prevention Training Centers (NNPTC): Evaluation

OMB No. 0920-0995

Attachments 27 & 28

Treatment Guidelines Short Long-term Evaluation Instrument

Word version and screenshot

TODAY’S DATE

____________________________

M M D D Y Y

Your confidential ID number is the first two letters of your FIRST name, the first two letters of your LAST name, the MONTH of your birth, and the DAY of your birth.

FN	FN	LN	LN	M	M	D	D

CONFIDENTIAL IDENTIFIER

Condensed STD Treatment Short Long-Term Evaluation

Public reporting burden of this collection of information is estimated to average 3minutes 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: PRA (0920-0995).

A8f. Did you incorporate any of the information presented into your patient care, practice setting or job?

 Yes

 No

 Not applicable to my practice or patients

 I was already performing the recommended practices

 Other (please specify) ______________________________________

As a result of information presented in this training did you …

	Yes	No	NA	I was already doing this
SGCH2f …download the CDC STD Treatment Guidelines app?	1	0	2	3
SGCH3f …increase the proportion of your sexually active asymptomatic female patients under age 25 screened for urogenital chlamydia and gonorrhea?	1	0	2	3
SGCH4f …increase the proportion of your male patients who have sex with men screened for syphilis, gonorrhea, and chlamydia at least annually?	1	0	2	3
SGCH5f …use dual antibiotic therapy to treat uncomplicated gonorrhea?	1	0	2	3
SGCH6f …send a consult to the STD Clinical Consultation Network? www.stdccn.org	1	0	2	3
SGCH7f …recommend rescreening in 3 months following a gonorrhea, chlamydia or trichomonas diagnosis?	1	0	2	3
SGCH8f …use the STD Treatment Guidelines wall chart or pocket guide?	1	0	2	3
SGCH9f …share information about the STD Treatment Guidelines with others?	1	0	2	3

EPTf As a result of information presented in this training did you provide Expedited Partner Therapy (EPT) to

heterosexual partners of those diagnosed with gonorrhea and/or chlamydia?

 Yes

 No

 Not applicable to my practice or job

 Not allowed in my state/practice

 My practice/worksite is in the planning stages to offer EPT

 My practice/worksite already offered EPT

 EPT was not discussed

A6f. Did any of these factors MAKE IT HARDER for you to incorporate the STD practices recommended in the presentation? (select all that apply)

 lack of time with patients

 more important patient concerns

 cost/lack of reimbursement

 policies where I work

 resistance to change by supervisor or colleagues

 lack of equipment or supplies

 no opportunity to apply practices

 nothing interfered

 other, please specify ___________________________________________________

A7f. Did any of these factors HELP you incorporate the STD practices recommended in the presentation?

(select all that apply

 reimbursement or other financial incentive

 support of supervisor and/or colleagues

 standing orders

 reminder in chart

 convenient supplies

 posted patient instructions for obtaining specimens

 nothing specific helped

 other, please specify ___________________________________________________

UseGuidef Do you use the CDC STD Treatment Guidelines to guide the care of your patients/clients?

No, I am not aware of the Guidelines

I am aware of the Guidelines but do not use them

I use the Guidelines occasionally

I use the Guidelines consistently

I use another source to guide my STD care (please specify) ______________

KG1f What is the CDC recommended treatment for a patient diagnosed with uncomplicated urethral

gonorrhea?

 Ceftriaxone 250 mg intramuscularly only

 Azithromycin 2 g orally in a single dose only

 Ceftriaxone 250 mg intramuscularly plus azithromycin 1 g orally in a single dose

 Cefixime 400 mg orally plus doxycycline 100 mg orally BID for 7 days

 

KSG1f What is the recommended follow-up for a non-pregnant patient after diagnosis and treatment

of chlamydia, gonorrhea, and/or trichomonas?

   A test of cure at 2 weeks, and repeat test at 3 months

 A test of cure at 2 weeks, and repeat test at 12 months

 Repeat test in 3 months

 Repeat test in 12 months

 

KSG2f What is recommended for STD screening of an HIV-negative man who reports oral sex (oral and penile

exposure) and receptive anal sex with multiple male partners?

   Pharyngeal GC, rectal GC/CT, urethral GC/CT and syphilis every 3-6 months

 Pharyngeal GC, Rectal GC/CT, urethral GC/CT and syphilis every 12-24 months

 Urethral GC/CT and syphilis every 3-6 months, with pharyngeal GC and rectal GC/CT if symptoms are present

 Urethral GC/CT and syphilis every 12-24 months, with pharyngeal GC and rectal GC/CT if symptoms are present