Form 3 Monthly Data Report Form for Bacterial Specimen Testing

Form Approved

OMB Control No.: 0920-1310

Expiration date: XX/XX/XXXX

Monthly Data Report Form

Data element Name	Data element Definition
Program_or_pathogen	ARLN program
Reported_to_submitter_date	Date reported to the submitter (clinical lab or healthcare facility of origin) by the jurisdictional PHL Granularity = day
Clinical_sample_or_isolate	Indicates whether the specimen received for testing was a clinical sample or an isolate
Reporting_month	This is the year and month this report is counted for CDC reporting; it is based on the date of collection.
Patient_ID	1.Unique patient ID assigned by the public health department, 2. Unique patient ID assigned by the ARLN testing lab. This could be the Accession number of the isolate tested by PHLab (Also known as the ARLN specimen ID), or 3. Other unique patient ID
Patient_age	Age at specimen collection date
Patient_age_unit	Could be years, months, days
Patient_sex	This is the administrative sex (PID-8)
PHL	The coded representation of any state PHL plus PR and some city labs
ARLN_PHL	The coded representation of the ARLN regional lab
Healthcare_facility_of_origin_ID	All: ID of the Healthcare facility of origin (ad-289) Where patient is located when testing was initiated. Preferred ID type is either the NPI or the Medicare ID (collected by NHSN program, so helpful for linking)
Healthcare_facility_of_origin_name	All: Where the patient was located when testing was initiated. For CPO Colonization this may be the same “submitter” (duplicate of data contained in Submitter_facility_name). Example: Fairview Hospital
Healthcare_facility_of_origin_state	State of the healthcare facility of origin (ad-289)
Healthcare_facility_of_origin_zipcode	Zip code of the healthcare facility of origin (ad-289)
Processing_Laboratory_ID	CRE/CRPA/CRAB/CPO col This is the ID for the Processing laboratory (ad-192). The preferred identifier type to use is CLIA number, NPI is also allowed.
Submitter_facility_ID	ID of the submitting facility (ad-124)
Submitter_facility_name	The name of the facility or clinical laboratory that collected and processed the specimen and sent it (and a request for testing) to the ARLN lab, and to which the testing public health lab is reporting the results back to.
Submitter_facility_state	State of the submitting facility (ad-124)
Submitter_facility_zipcode	Zip code of the submitting facility (ad-124)
Specimen_collection_date	Date or Date/Time specimen collected
Specimen_received_date	Date or Date/Time specimen received for ARLN testing
Submitter_Specimen_ID	This is the Specimen ID assigned by the submitting entity (facility, laboratory, etc). This is the placer specimen ID and is populated in SPM-2.1.
ARLN_Specimen_ID	The ARLN_Specimen_ID is the testing lab's specimen ID, this is also the filler specimen ID, which is populated in SPM 2.2.
Specimen_type	Specimen type This is describing the clinical specimen.
Isolate_forwarded_to_RegLab	Identifies that the PHL has forwarded an isolate to an ARLN regional lab for additional testing.
Date_forwarded_to_RegLab	The date a PHL has forwarded an isolate to an ARLN regional lab (ad-159) for additional testing. Granularity = day
Organism_tested	Identifies the organism that testing was performed on
Confirmed_carbapenem_resistant	Was the phenotypic test result confirmed by AST testing (Yes/No)
AST_method_used	Identifies which method of susceptibility testing was used; e.g. Etest, broth micro dilution, disk diffusion
Amikacin_AST_MIC	Amikacin MIC
Amikacin_AST_zone_diameter	Amikacin zone diameter
Ciprofloxacin_AST_MIC	Ciprofloxacin MIC
Ciprofloxacin_AST_zone_diameter	Ciprofloxacin zone diameter
Doxycycline_AST_MIC	Doxycycline MIC
Doxycycline_AST_zone_diameter	Doxycycline zone diameter
Gentamicin_AST_MIC	Gentamicin MIC
Gentamicin_AST_zone_diameter	Gentamicin zone diameter
HP_Aztreonam_MIC	Aztreonam MIC by HP printer method
HP_Aztreonam_Avibactam_MIC	Aztreonam Avibactam MIC by HP printer method
HP_Ceftazidime_Avibactam_MIC	Ceftazidime Avibactam MIC by HP printer method
HP_Ceftazidime_Aztreonam_Avibactam_MIC	Ceftazidime Aztreonam Avibactam MIC by HP printer method
HP_new_drug_mic	New drug MIC tested using HP Printer method
Aztreonam_AST_MIC	Numeric value (SN data type)
Aztreonam_AST_zone_diameter	Numeric value (SN data type)
Cefepime_AST_MIC	Numeric value (SN data type)
Cefepime_AST_zone_diameter	Numeric value (SN data type)
Cefotaxime_AST_MIC	Numeric value (SN data type)
Cefotaxime_AST_zone_diameter	Numeric value (SN data type)
Cefotaxime_clavulanate_AST_MIC	Numeric value (SN data type)
Cefotaxime_clavulanate_AST_zone_diameter	Numeric value (SN data type)
Ceftazidime_AST_MIC	Numeric value (SN data type)
Ceftazidime_AST_zone_diameter	Numeric value (SN data type)
Ceftazidime_clavulanate_AST_MIC	Numeric value (SN data type)
Ceftazidime_clavulanate_AST_zone_diameter	Numeric value (SN data type)
Ceftriaxone_AST_MIC	Numeric value (SN data type)
Ceftriaxone_AST_zone_diameter	Numeric value (SN data type)
Colistin_AST_MIC	Numeric value (SN data type)
Doripenem_AST_MIC	Numeric value (SN data type)
Doripenem_AST_zone_diameter	Numeric value (SN data type)
Ertapenem_AST_MIC	Numeric value (SN data type)
Ertapenem_AST_zone_diameter	Numeric value (SN data type)
Imipenem_AST_MIC	Numeric value (SN data type)
Imipenem_AST_zone_diameter	Numeric value (SN data type)
Meropenem_AST_MIC	Numeric value (SN data type)
Meropenem_AST_zone_diameter	Numeric value (SN data type)
Piperacillin_tazobactam_AST_MIC	Numeric value (SN data type)
Piperacillin_tazobactam_AST_zone_diameter	Numeric value (SN data type)
Other_3rdGen_cephalosporin_name	If another 3rd generation cephalosporin was tested, specify its name
Other_3rdGen_cephalosporin_AST_MIC	Numeric value (SN data type)
Other_3rdGen_cephalosporin_AST_zone_diameter	Susceptibility result for other 3rd generation cephalosporin. Method is disk diffusion
Other_new_drug	New drug name
Other_new_drug_result	New drug MIC/Zone diameter results
PCR_method_used	Identifies which PCR test method was used; e.g. Cepheid Xpert Carba-R assay, CDC assay, Other assay.
IMP_gene	Result of PCR for IMP carbapenemase gene
KPC_gene	Result of PCR for KPC carbapenemase gene
mcr_1_gene	Result of PCR for mcr-1 mobile colistin resistance gene
mcr_2_gene	Result of PCR for mcr-2 mobile colistin resistance gene
mcr_3_gene	Result of PCR for mcr-3 mobile colistin resistance gene
mcr_4_gene	Result of PCR for mcr-4 mobile colistin resistance gene
NDM_gene	Result of PCR for NDM carbapenemase gene
OXA_48_like_gene	Result of PCR for OXA-48-like carbapenemase gene
OXA_24_40_gene	Result of PCR for OXA-24/40-like carbapenemase gene
OXA_58_gene	Result of PCR for OXA-58-like carbapenemase gene
OXA_235_gene	Result of PCR for OXA-235-like carbapenemase gene
OXA_23_gene	Provisional definition: Result of PCR for OXA-23-like carbapenemase gene
VIM_gene	Result of PCR for VIM carbapenemase gene
Other_gene_name	Free text entry to name the carbapenemase gene that was tested for, that is not pre-defined.
Other_gene_result	Result of PCR for other carbapenemase gene
WGS_SRA	NCBI SRA Accession number (SRX#), is one of the IDs generated by NCBI when public health labs upload whole genome sequence data to NCBI. This provides access to both the sequence data and metadata connected with the isolate and serves as the link between sequencing data and phenotypic data generated for each isolate.
WGS_MetaData	any data associated with the WGS isolates
Outbreak_ID	ID assigned to isolates for outbreak purposes
RegLab_comment	Any comment from the ARLN Regional Lab
Index_case_information	Elements associated with index case that initiates screening in a facility (may include organism, resistance mechanisms, public health ID, or facility ID).

Public reporting burden of this collection of information is estimated to average 240 minutes 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 0920-1310