Form 9 AR Lab Network Alert and Monthly Data Report Form for Ne

Form Approved

OMB Control No.: 0920-1310

Expiration date: XX/XX/XXXX

AR Lab Network Alert and Monthly Data Report Form for Neisseria gonorrhoeae

Unique AR Lab Network Specimen ID

Project

Patient Age

Gender

Submitting State

Travel History

Reason(s)for Requesting AST

If requesting due to treatment failure: What treatment was administered/dispensed at initial evaluation (optional)?

Specimen Source

Specimen Collection Date

Test Date

CRO MIC

If CRO alert MIC: Was confirmatory testing performed? What was the MIC?

CFM MIC

If CRO alert MIC: Was confirmatory testing performed? What was the MIC?

AZI MIC

CIP MIC

Public reporting burden of this collection of information is estimated to average 6 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