Form 6 Monthly Data Report Form Candida

Form Approved

OMB Control No.: 0920-1310

Expiration date: XX/XX/XXXX

Monthly Data Report Form – Candida identification

Data element Name	Data element Definition
Yourlab_state	State or jurisdiction of the AR Lab Network lab submitting this data
Reporting_month	This is the year and month this report is counted for CDC reporting; it is based on the date of collection.
Reported_to_submitter_date	Date reported to the submitter (clinical lab or healthcare facility of origin) by the jurisdictional PHL Granularity = day
Patient_ID	1) Unique patient ID assigned by the public health department. 2) Unique patient ID assigned by the hospital/facility. 3) Other unique patient ID. The patient ID should facilitate linking lab data to data provided from epidemiologists and other sources in public health.
Patient_age	Age at specimen collection date
Patient_age_unit	Could be years, months, days
Patient_sex	Patient sex
Patient_race	Patient race
Patient_ethnicity	Patient ethnicity
Patient_county	County of residence
Patient_county_code	County code of residence
Patient_state	State of residence
Patient_country	Country of residence
ARLN_PHL_sent	The coded representation of the ARLN regional lab where the isolate was sent (if it was sent)
Processing_Laboratory_ID	ID for the processing laboratory
Processing_laboratory_name	The lab that isolates the organism or that collects and processes clinical specimens (when not the healthcare facility of origin). This can be a public health lab or clinical lab.
FacilityID	ID of the healthcare facility of origin (i.e., where patient was located when testing was initiated)
FacilityName	Where the patient was located when testing was initiated.
FacilityState	State of the healthcare facility of origin
Submitter_facility_ID	ID of the submitting facility
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 AR Lab Network lab, and to which the testing public health lab is reporting the results back to.
Submitter_facility_state	State of the submitting facility
Submitter_facility_zipcode	Zip code of the submitting facility
Specimen_collection_date	Date specimen collected
Specimen_received_date	Date specimen received for ARLN testing
Submitter_Specimen_ID	This is the Specimen ID assigned by the submitting entity (facility, laboratory, etc).
ARLN_Isolate_ID	The ARLN Isolate ID is the testing lab’s isolate ID
ARLN_Specimen_ID	The ARLN_Specimen_ID is the testing lab's specimen ID
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 for additional testing. Granularity = day
Test_date	Date the test was performed
Species_identified_by_clinical_lab	Species identified at the clinical lab
Species_identified_by_yourlab	Species identified at the AR Lab Network lab
Yourlab_comment	Comments from the AR Lab Network lab
reporting_complete	Completion status
Organism_Suspected	Organism that is suspected, or intended to be ruled out, as recorded on the order

Public reporting burden of this collection of information is estimated to average 120 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