STD Surveillance Network (SSuN)
Revision Request
SSuN Data Elements
Attachment 5
OMB# 0920-1072
May 12, 2023
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OMB Control# 0920-1072 (Expires XX/XX/XXXX) |
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DE # |
Data Element Name |
Description/Response Coding |
Strategy A (STD Clinic) Data Elements |
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1 |
F1_FacilityID |
Unique facility identifier |
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This ID should be supplied by the site and is a unique facility identifier from underlying surveillance systems or may be generated specifically for SSuN. Regardless of source, this ID must be unique and allow for longitudinal tracking of the facility. This data element MUST NOT be ‘null’ or contain missing values. |
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2 |
F1_SiteID |
Unique site code |
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BA=Baltimore (Cycle II, Cycle III, Cycle IV) |
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CB=Columbus Ohio (Cycle IV) |
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CA=California (Cycle II, Cycle III, Cycle IV) |
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FL=Florida (Cycle III & Cycle IV) |
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IN=Indiana (Cycle IV) |
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MC=Multnomah County (Cycle III &Cycle IV) |
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NY=New York City (Cycle II, Cycle III, Cycle IV) |
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PH=Philadelphia (Cycle II, Cycle III, Cycle IV) |
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SF=San Francisco (Cycle II, Cycle III, Cycle IV) |
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WA=Washington (Cycle II, Cycle III, Cycle IV) |
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UT=UTAH (Cycle IV) |
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LA=Louisana (Cycle II) |
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VA=Virginia (Cycle II) |
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AL=Alabama (Cycle II) |
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CO=Colorado (Cycle II) |
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CH=Chicago (Cycle II) |
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MA=Massachusetts (Cycle III) |
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MN=Minnesota (Cycle III) |
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This data element MUST NOT be ‘null’ or contain missing values. |
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3 |
F1_PatientID |
Unique patient identification number assigned by site |
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This ID should be supplied by the site and may be a unique patient identifier from underlying surveillance systems or may be generated specifically for SSuN. Regardless of source, this ID must be unique and allow for longitudinal tracking of patients within facilities. This data element MUST NOT be ‘null’ or contain missing values. |
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4 |
F1_Visdate |
Date of clinic visit |
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This data element MUST NOT be ‘null’ or contain missing values except for HIV eHARS lab match records. |
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5 |
F1_EventID |
Unique visit identification |
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This record ID should be supplied by the site and may be an event or visit ID assigned at the clinic level |
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6 |
F1_sex_Birth |
What is the patient’s assigned sex at birth? |
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1= Male |
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2= Female |
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3=Intersex |
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4=Unknown |
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9=Not Captured |
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A response of 9 indicates the information is not captured or collected by the facility or is not provided to SSuN. A response of null indicates that the facility or is not provided to SSuN. |
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7 |
F1_Gender_Identity |
What is the patient's gender identity? |
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1= Male |
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2= Female |
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3=Transgender M to F |
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4=Transgender F to M |
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5=Transgender, Unknown or Unspecified |
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6= Gender Queer/Non-Binary |
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7= Other |
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9= Not captured |
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A response of 9 indicates the information is not captured or collected by the facility or is not provided to SSuN. A response of null indicates that the information is collected by the facility but is unknown for this record. |
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8 |
F1_Age |
How old is this patient? (Age in years). |
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If age is unknown or missing, use null value. |
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For the following race/ethnic questions below: Indicate yes for all of the race/ethnic questions that apply. A response of 9 indicates the information is not captured/ collected by the facility or is not provided to SSuN. Response should be null if (1) race is collected by the facility but is unknown for this record, or (2) a response of “no” is not collected separately. |
9 |
F1_Hisp |
Is the patient of Hispanic ethnicity? |
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1= Yes |
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2= No |
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9= Not captured |
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10 |
F1_AIAN |
Is the patient American Indian or Alaskan Native? |
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1= Yes |
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2= No |
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9= Not captured |
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11 |
F1_Asian |
Is the patient Asian? |
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1= Yes |
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2= No |
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9= Not captured |
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12 |
F1_PIH |
Is the patient Native Hawaiian or Pacific Islander? |
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1= Yes |
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2= No |
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9= Not captured |
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13 |
F1_Black |
Is the patient Black? |
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1= Yes |
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2= No |
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9= Not captured |
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14 |
F1_White |
Is the patient White? |
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1= Yes |
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2= No |
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9= Not captured |
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15 |
F1_Multirace |
Is the patient Multirace? |
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1= Yes |
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2= No |
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9= Not captured |
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16 |
F1_Otherrace |
Is the patient another race not listed above? |
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1= Yes |
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2= No |
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9= Not captured |
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Indicate yes for all of the race/ethnic questions that apply. A response of 9 indicates the information is not captured/ collected by the facility or is not provided to SSuN. Response should be null if (1) race is collected by the facility but is unknown for this record, or (2) a response of “no” is not collected separately. |
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17 |
F1_Insurance |
What is the primary health insurance status of the patient (regardless of whether it is used for the clinic visit)? |
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1= Insured, Public only |
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2= Insured, Private only |
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3= Insured, Multiple types |
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4=Unknown type |
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5=Uninsured |
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9= Insurance status not captured |
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A response of 9 indicates the information is not captured or collected by the facility or is not provided to SSuN. A response of null indicates that the information is collected but is unknown for this record. |
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18 |
F1_Visit_type |
Type of clinic visit |
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1 = Clinician |
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2= express/fast track |
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3=Telemedicine - Clinician Visit |
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4=Telemedicine - Express Visit |
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8= Other |
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9= Not captured |
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A response of 9 indicates the information is not captured or collected by the facility or not provided to SSuN. A response of null indicates that the information is collected but is unknown for this record. |
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19 |
F1_Reason_visit |
What was the primary purpose of the visit? |
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1= Symptomatic/new problem |
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2= Treatment only/Positive STD Test |
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3= Follow-up |
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4= Family planning(retired) |
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5= STD/HIV screening only |
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6= Prenatal care (retired) |
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7=PrEP Visit |
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8= Other |
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9= Not captured |
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A response of 9 indicates the information is not captured or collected by the facility or is not provided to SSuN. The response options 4 and 6 are no longer to be used but left here for historical purposes. Although multiple response options may be applicable to a single clinic visit, please give prescedence to the symptomatic/new problem option. A response of null indicates that the information is collected but is unknown for this record. |
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20 |
F1_Pregnant |
Does the female patient self-report being currently pregnant? |
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1= Yes |
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2= No |
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3= Patient does not know/ not sure |
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9= Not captured |
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If information is collected but patient is not sure, then appropriate response is 3. A response of 9 indicates the information is not captured or collected by the facility or is not provided to SSuN. Null values allowed for men or if information is collected by the facility but unknown for this record. |
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21 |
F1_Sympt |
Did the patient present with symptoms consistent with a STI (includes genital pain, itching, dysuria, genital sores or rash, vaginal/penile/rectal discharge? |
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1= Yes |
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2= No |
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9= Not captured |
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A response of 9 indicates the information is not captured or collected by the facility or is not provided to SSuN. A response of null indicates that the information is collected by the facility but is unknown for this record. |
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22 |
F1_Contact_GC |
Was the patient a contact to or exposed to gonorrhea? |
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1= Yes |
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2= No |
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9= Not captured |
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A response of 9 indicates the information is not captured or collected by the facility or is not provided to SSuN. A response of null indicates that the information is collected by the facility but is unknown for this record. |
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22.1 |
F1_Contact_CT |
Was the patient a contact to or exposed to chlamydia? |
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1= Yes |
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2= No |
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9= Not captured |
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A response of 9 indicates the information is not captured or collected by the facility or is not provided to SSuN. A response of null indicates that the information is collected by the facility but is unknown for this record. |
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22.2 |
F1_contact_SY |
Was the patient a contact to or exposed to syphilis? |
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1= Yes |
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2= No |
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9= Not captured |
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A response of 9 indicates the information is not captured or collected by the facility or is not provided to SSuN. A response of null indicates that the information is collected by the facility but is unknown for this record. |
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22.3 |
F1_contact_Other |
Was the patient a contact or exposed to a STD (other than syphilis, chlamydia, or gonorrhea)? |
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1= Yes, HSV |
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2= Yes, MPX |
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3. Yes, multiple |
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4. Yes, don’t know specific STD |
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5. No, not a contact or exposed to STD |
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9= Not captured |
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A response of 9 indicates the information is not captured or collected by the facility or is not provided to SSuN. A response of null indicates that the information is collected by the facility but is unknown for this record. |
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23 |
F1_Pelvic_exam |
Was a pelvic exam performed? |
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1= Yes |
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2= No |
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9= Not captured |
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A response of 9 indicates the information is not captured or collected by the facility or is not provided to SSuN. Null values allowed for men or if information is collected by the facility but unknown for this record. |
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24 |
F1_MENSEX |
In the past 3 months, how many sex partners with male genitalia does the patient report? |
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If number of male sex partners is unknown, missing, or not captured, use null value. |
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25 |
F1_FEMSEX |
In the past 3 months, how many sex partners with female genitalia does the patient report? |
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If number of female sex partners is unknown, missing, or not captured, use null value. |
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26 |
F1_TRANSEX |
In the past 3 months, how many sex partners reported to be transgendered does the patient report? |
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If number of female sex partners is unknown, missing, or not captured, use null value. |
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28 |
F1_SEXOR3 |
In the past 3 months, who does the patient report as sex partners? |
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1= Partners with male genitalia only |
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2= Partners with female genitalia only |
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3= Both |
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4= No Sex Partners Last 3 Mos |
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9= Not captured |
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A response of 9 indicates the information is not captured or collected by the facility or is not provided to SSuN. A response of null indicates that the information is collected by the facility but is unknown for this record. |
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29 |
F1_SEXOR3TG |
In the past 3 months, does the patient report having sex with a transgendered person (transgender man, transgender woman, or transgender unspecified)? |
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1= Yes |
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2= No |
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9= Not captured |
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A response of 9 indicates the information is not captured or collected by the facility or is not provided to SSuN. A response of null indicates that the information is collected by the facility but is unknown for this record. |
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30 |
F1_NUMSEX3 |
In the past 3 months, how many sexual partners does the patient report? |
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If number of sex partners is unknown, missing, or not captured, use null value. |
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31 |
F1_SEXUALITY |
How does the person characterize their sexual orientation? |
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1= Gay/lesbian/homosexual |
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2= Straight/heterosexual (not Gay or Lesbian) |
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3= Bisexual |
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4= Other |
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9 = Not captured |
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A response of 9 indicates the information is not captured or collected by the facility or is not provided to SSuN. A response of null indicates that the information is collected by the facility but is unknown for this record. |
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32 |
F1_NewSex |
In the last 3 months, does the patient report having a new sexual partner(s)? |
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1= Yes |
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2= No |
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9= Not captured |
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A response of 9 indicates the information is not captured or collected by the facility or is not provided to SSuN. A response of null indicates that the (1) information is collected by the facility but is unknown for this record or (2) that there was not an opportunity for a “no” response. |
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33 |
F1_Rectal_exposure |
In the past 3 months, does the patient report receptive anal sex with a male sexual partner? |
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1= Yes |
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2= No |
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9= Not captured |
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A response of 9 indicates the information is not captured or collected by the facility or is not provided to SSuN. A response of null indicates that the (1) information is collected by the facility but is unknown for this record or (2) that there was not an opportunity for a “no” response. |
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34 |
F1_Oral_Sex |
In the past 3 months, does the patient report oral receptive sex with a male sexual partner? |
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1= Yes |
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2= No |
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9= Not captured |
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A response of 9 indicates the information is not captured or collected by the facility or is not provided to SSuN. A response of null indicates that the (1) information is collected by the facility but is unknown for this record or (2) that there was not an opportunity for a “no” response. |
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35 |
F1_condom |
In the past 3 months, does the patient report condomless sex (may include receptive anal or vaginal sex) with a male sexual partner? |
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1= Yes |
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2= No |
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3= Patient not sure/ unknown /refused |
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9= Not captured |
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A response of 9 indicates the information is not captured or collected by the facility or is not provided to SSuN. A response of null indicates that the (1) information is collected by the facility but is unknown for this record or (2) that there was not an opportunity for a “no” response. |
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36 |
F1_HIV_partner |
In the past 12 months, does the patient report having sex with a person living with HIV/AIDS? |
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1= Yes |
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2= No |
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3= Patient not sure/ unknown /refused |
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9= Not captured |
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A response of 9 indicates the information is not captured or collected by the facility or is not provided to SSuN. A response of null indicates that the (1) information is collected by the facility but is unknown for this record or (2) that there was not an opportunity for a “no” response. |
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37 |
F1_IVDU |
In the past 3 months, does the patient report use of illicit injected drugs? |
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1= Yes |
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2= No |
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3= Patient not sure/ unknown /refused |
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9= Not captured |
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If information is collected by the facility but patient is not sure, then appropriate response is 3. A response of 9 indicates the information is not captured or collected by the facility or is not provided to SSuN. A response of null indicates that the (1) information is collected by the facility but is unknown for this record or (2) that there was not an opportunity for a “no” response. |
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38 |
F1_OPIOID |
In the past 3 months, does the patient report use of opioids (but not under a physician's orders)? |
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1= Yes |
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2= No |
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3= Patient not sure/ unknown /refused |
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9= Not captured |
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If information is collected by the facility but patient is not sure, then appropriate response is 3. A response of 9 indicates the information is not captured or collected by the facility or is not provided to SSuN. A response of null indicates that the (1) information is collected by the facility but is unknown for this record or (2) that there was not an opportunity for a “no” response. |
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38.1 |
F1_Prep_Scrn |
Was this patient counseled and screened for PrEP eligibility? |
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1=Yes |
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2=No, Patient HIV+ |
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3=No, Patient Refused |
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4=No, Express Visit Only |
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9= Not captured |
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A response of 9 indicates the information is not captured or collected by the facility or is not provided to SSuN. Null value not allowed. |
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38.2 |
F1_Prep_Elig |
Was this patient eligible for PrEP? |
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1=Yes |
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2=No, Patient Not Eligible (HIV+) |
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3=No, Patient Not Eligible (Other Reason) |
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9= Not captured |
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A response of 9 indicates the information is not captured or collected by the facility or is not provided to SSuN. Null value not allowed. |
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38.3 |
F1_Prep_Ref |
Was this patient referred for PrEP services? |
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1=Yes, Referred to in-house PrEP specialist |
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2=Yes, Referred to external PrEP provider |
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3=No, Patient Not Eligible |
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9= Not captured |
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A response of 9 indicates the information is not captured or collected by the facility or is not provided to SSuN. Null value not allowed. |
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38.4 |
F1_Prep_Rx |
Was this patient prescribed PrEP at this visit? |
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1=Yes, Initial PrEP prescription given |
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2=Yes, Prescription refilled |
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3=No, Patient not prescribed PrEP |
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9= Not captured |
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A response of 9 indicates the information is not captured or collected by the facility or is not provided to SSuN. Null value not allowed. |
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39 |
F1_PrEP |
Is the patient currently on PrEP? |
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1= Yes |
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2= No |
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3= Patient not sure/ unknown /refused |
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9= Not captured |
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If information is collected by the facility but patient is not sure, then appropriate response is 3. A response of 9 indicates the information is not captured or collected by the facility or is not provided to SSuN. A response of null indicates that the information is collected but is unknown for this record. |
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40 |
F1_PEP_rec |
Was the patient dispensed/provided HIV PEP at this STD clinic visit? |
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1= Yes |
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2= No |
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9= Not captured |
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A response of 9 indicates the information is not captured or collected by the facility or is not provided to SSuN. A response of null indicates that the information is collected but is unknown for this record. |
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41 |
F1_PrEP_rec |
Was the patient dispensed/provided PrEP at this STD clinic visit? |
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1= Yes |
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2= No |
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9= Not captured |
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A response of 9 indicates the information is not captured or collected by the facility or is not provided to SSuN. A response of null indicates that the information is collected but is unknown for this record. |
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41.1 |
F1_dPEP_Rx |
Was the patient prescribed doxycycline post-exposure prophylaxis at this visit? |
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1=Yes |
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2=No |
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9=Not Captured |
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A response of 9 indicates the information is not captured or collected by the facility or is not provided to SSuN. Null value not allowed. |
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42 |
F1_Partner_tx |
Was the patient prescribed or given medication for expedited partner therapy at this visit? |
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1= Yes |
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2= No |
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9= Not captured |
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A response of 9 indicates that EPT is provided by the facility, but information is not captured or collected or is not provided to SSuN. A response of null indicates that the (1) information is collected by the facility but is unknown for this record, or (2) information is collected by the facility but there is not an opportunity for a “no” response. |
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42.1 |
F1_MPOX_VaxHx |
Has this patient been previously vaccinated for smallpox or mpox? |
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1=Yes, fully vaccinated |
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2=Yes, not fully vaccinated |
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3=No, no prior smallpox or mpox vaccination |
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4=Refused to provide vaccination information |
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9=Not captured |
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42.2 |
F1_MPOX_VaxDATE |
If patient previously vaccinated for smallpox or mpox, date of most recent dose. |
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MM/YY |
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../.. |
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42.3 |
F1_MPOX_Vax |
Was this patient vaccinated for smallpox or mpox at this visit? |
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1=Yes, Administered Initial Dose |
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2=Yes, Administered Second Dose |
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3=Yes, Administered >2nd dose |
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4=No, no MPX vaccine administered |
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9= Not captured |
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A response of 9 indicates the information is not captured or collected by the facility or is not provided to SSuN. Null value not allowed. |
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42.4 |
F1_MPOX_Vax_Spec |
What smallpox or mpox vaccine was administered at this visit? |
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1=JYNNEOS (Imvamune or Imvanex) |
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2=ACAM2000 |
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A response of 9 indicates the information is not captured or collected by the facility or is not provided to SSuN. Null value not allowed if F1_MPX_Vax= 1,2 or 3. |
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42.5 |
F1_MPOX_Vx_Mthd |
What was the method of smallpox or mpox vaccine administration at this visit? |
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1=Intradermal (ID) |
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2=Subcutaneous (SQ) |
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9= Not captured |
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A response of 9 indicates the information is not captured or collected by the facility or is not provided to SSuN. Null value not allowed if F1_MPX_Vax= 1,2 or 3. |
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42.6 |
F1_MPOX_Vx_Lot |
What is the vaccine lot number of the vaccine administered at this visit? |
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Text |
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A response of 9999 indicates the information is not captured or collected by the facility or is not provided to SSuN. Null value not allowed if F1_MPX_Vax= 1,2 or 3. |
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42.7 |
F1_MPOX_Vx_dosage |
What vaccine dose was administered at this visit? |
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##### |
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A response of 9999 indicates the information is not captured or collected by the facility or is not provided to SSuN. Null value not allowed if F1_MPX_Vax= 1,2 or 3. |
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42.8 |
F1_MPOX_Vx_dosUnit |
What was the vaccine dose unit for the vaccine administered at this visit? |
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1=mL |
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2=CC |
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3=mG |
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4=μG (microgram) |
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9=Not Captured |
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A response of 9 indicates the information is not captured or collected by the facility or is not provided to SSuN. Null value not allowed if F1_MPX_Vax= 1,2 or 3 |
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43 |
F1_SXRectal |
Does the patient report rectal symptoms (e.g., discharge, pain, itching, bleeding)? |
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1= Yes |
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2= No |
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9= Not captured |
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A response of 9 indicates the information is not captured or collected by the facility or is not provided to SSuN. Null values are allowed if the information is collected by the facility but (1) is unknown for this record or (2) there is not an opportunity for a “no” response. |
|
|
|
44 |
F1_SXPharyngeal |
Does the patient report oral symptoms (e.g., soreness, pain, blisters)? |
|
|
1= Yes |
|
|
2= No |
|
|
9= Not captured |
|
|
A response of 9 indicates the information is not captured or collected by the facility or is not provided to SSuN. Null values are allowed if the information is collected by the facility but (1) is unknown for this record or (2) there is not an opportunity for a “no” response.. |
|
|
|
45 |
F1_SXAbdomen |
Did the patient report abdominal pain? |
|
|
1= Yes |
|
|
2= No |
|
|
9= Not captured |
|
|
A response of 9 indicates the information is not captured or collected by the facility or is not provided to SSuN. Null values are allowed if the information is collected by the facility but (1) is unknown for this record or (2) there is not an opportunity for a “no” response. |
|
|
|
46 |
F1_SXDysuria |
Did the patient report dysuria? |
|
|
1= Yes |
|
|
2= No |
|
|
9= Not captured |
|
|
A response of 9 indicates the information is not captured or collected by the facility or is not provided to SSuN. Null values are allowed if the information is collected by the facility but (1) is unknown for this record or (2) there is not an opportunity for a “no” response. |
|
|
|
47 |
F1_SXDischarge |
Did the patient report a vaginal (abnormal), rectal or penile discharge?" |
|
|
1= Yes |
|
|
2= No |
|
|
9= Not captured |
|
|
A response of 9 indicates the information is not captured or collected by the facility or is not provided to SSuN. Null values are allowed if the information is collected by the facility but (1) is unknown for this record or (2) there is not an opportunity for a “no” response. |
|
|
|
48 |
F1_SXLesion |
Does the patient report an oral or genital ulcer/blister? |
|
|
1= Yes |
|
|
2= No |
|
|
9= Not captured |
|
|
A response of 9 indicates the information is not captured or collected by the facility or is not provided to SSuN. Null values are allowed if the information is collected by the facility but (1) is unknown for this record or (2) there is not an opportunity for a “no” response. |
|
|
|
48.1 |
F1_Sxitching |
Did the patient report a vaginal (abnormal), rectal or penile (urethral) itching? |
|
|
|
|
|
1= Yes |
|
|
2= No |
|
|
9= Not captured |
|
|
A response of 9 indicates the information is not captured or collected by the facility or is not provided to SSuN. Null values are allowed if the information is collected by the facility but (1) is unknown for this record or (2) there is not an opportunity for a “no” response. |
|
|
|
48.2 |
F1_SXPain |
Did the patient report a vaginal (abnormal), rectal or genital pain? |
|
|
|
|
|
1= Yes |
|
|
2= No |
|
|
9= Not captured |
|
|
A response of 9 indicates the information is not captured or collected by the facility or is not provided to SSuN. Null values are allowed if the information is collected by the facility but (1) is unknown for this record or (2) there is not an opportunity for a “no” response. |
|
|
|
48.3 |
F1_SXRash |
Did the patient report a genital/anal rash? |
|
|
|
|
|
1= Yes |
|
|
2= No |
|
|
9= Not captured |
|
|
A response of 9 indicates the information is not captured or collected by the facility or is not provided to SSuN. Null values are allowed if the information is collected by the facility but (1) is unknown for this record or (2) there is not an opportunity for a “no” response. |
48.4 |
F1_Sxbleeding |
Did the patient report a vaginal (abnormal), rectal or (urethral ) penile bleeding? |
|
|
|
|
|
1= Yes |
|
|
2= No |
|
|
9= Not captured |
|
|
A response of 9 indicates the information is not captured or collected by the facility or is not provided to SSuN. Null values are allowed if the information is collected by the facility but (1) is unknown for this record or (2) there is not an opportunity for a “no” response. |
|
|
|
49 |
F1_PEDischarge |
Is there a finding of abnormal discharge on physical exam? |
|
|
1= Yes |
|
|
2= No |
|
|
9= Not captured |
|
|
A response of 9 indicates the information is not captured or collected by the facility or is not provided to SSuN. Null values are allowed if the information is collected by the facility but (1) is unknown for this record or (2) there is not an opportunity for a “no” response, or 3(patient is a female). |
|
|
|
50 |
F1_PEAbdomen |
Is there a finding of lower abdominal pain/tenderness on physical exam? |
|
|
1= Yes |
|
|
2= No |
|
|
9= Not captured |
|
|
A response of 9 indicates the information is not captured or collected by the facility or is not provided to SSuN. Null values are allowed if the information is collected by the facility but (1) is unknown for this record or (2) there is not an opportunity for a “no” response, or 3(patient is a female). |
|
|
|
53 |
F1_HIVTest |
Does the patient report ever tested for HIV? (excluding HIV testing on today’s visit)? |
|
|
1= Yes |
|
|
2= No |
|
|
3= Patient does not know/ not sure |
|
|
9= Not captured |
|
|
If information is collected by the facility but patient is not sure, then appropriate response is 3. A response of 9 indicates the information is not captured or collected by the facility or is not provided to SSuN. Null values allowed if information is collected by the facility but unknown for this record. |
|
|
|
54 |
F1_HIVTestdate |
When was the patient's most recent test for HIV (month and year)? (excluding HIV testing on today’s visit)? |
|
|
Null values are allowed if (1) response to F1_HIVTest is either 2, 3, 9 or (2) patient does not know/ or not sure of the date of most recent HIV test. |
|
|
|
55 |
F1_HIVResultlast |
What was the result of the patient's most recent test for HIV (excluding HIV testing on today’s visit)? |
|
|
0 = Negative |
|
|
1 = Positive/preliminary positive |
|
|
2 = Indeterminant |
|
|
3= Patient does not know/ not sure |
|
|
9 = Not captured |
|
|
A response of 9 indicates the information is not captured or collected by the facility or is not provided to SSuN. Null value are allowed if (1) response to F1_HIVTest is either 2, 3,9 or (2) patient does not know/ or not sure of the result of the most recent HIV test. |
|
|
|
56 |
F1_HIVTest_refuse |
Did the patient refuse an HIV test today? |
|
|
1= Yes |
|
|
2= No |
|
|
9= Not captured |
|
|
A response of 9 indicates the information is not captured or collected by the facility or is not provided to SSuN. Null values are allowed if the information is collected by the facility but is unknown for this record. |
|
|
|
57 |
F1_HregMatch |
Was eHARS registry match done for this patient? |
|
|
1=Yes |
|
|
2=No |
|
|
This data element may be initially coded as ‘2’ if the grantee conducts a batch match with their HIV registry and the case is reported before that batch is processed. This information can be updated in the SSuN record in the next data transmission following the match. This data element should not be ‘null’ or contain missing values. |
|
|
|
58 |
F1_HIVcare |
Is the patient currently in HIV care? |
|
|
1=Yes |
|
|
2=No |
|
|
3= Patient is not HIV positive |
|
|
4= Unknown |
|
|
9= Not captured |
|
|
A response of 9 indicates the information is not captured or collected by the facility or is not provided to SSuN. Null values are allowed if the information is collected by the facility but is unknown for this record. |
|
|
|
59 |
F1_HregMatchStat |
Did this patient match a registry entry in eHARS? |
|
|
1=Matching Record Found |
|
|
2=No Matching Record |
|
|
3=Match Not Performed |
|
|
This data element may be initially coded as ‘3’ if the grantee conducts a batch match with their HIV registry and the case is reported before that batch is processed. This information can be updated in the SSuN record in the next data transmission following the match. This data element should not be ‘null’ or contain missing values. |
|
|
|
60 |
F1_HregID |
Unique record number from HIV registry (such as stateno from eHARS). |
|
|
This data element should not be ‘null’ or contain missing values if a matching record is present in eHARS |
|
|
|
61 |
F1_HDXMOYR |
What is this patient's earliest indication of HIV positive result? |
|
|
This information can be obtained from the eHARS person table (HIVPMOYR) if eHARS match found (F1_HregMatchStat = 1). |
|
|
|
62 |
F1_EXPMOD |
Exposure mode from HIV registry. |
|
|
1=MSM Only |
|
|
2=IDU Only |
|
|
3=Heterosexual Contact Only |
|
|
4=MSM & IDU |
|
|
5=IDU & Heterosexual Contact |
|
|
6=MSM & Heterosexual Contact |
|
|
7=MSM, IDU & Heterosexual Contact |
|
|
8=Perinatal Exposure |
|
|
9=Other/Unknown |
|
|
This data element should not be ‘null’ or contain missing values if a matching record is present in eHARS (F1_HregMatchStat = 1). |
|
|
|
63 |
F1_HPVVaxadmin |
Was the patient given HPV vaccination at this visit? |
|
|
1= Yes |
|
|
2= No, not indicated/refused |
|
|
3= No, clinic does not administer/offer HPV vaccination |
|
|
9= Not captured |
|
|
A response of 9 indicates the information is not captured or collected by the facility or is not provided to SSuN. Null values are allowed if the information is collected by the facility but is unknown for this record. |
|
|
|
63.1 |
F1_MPXadmin |
Was the patient given MPX vaccination at this visit? |
|
|
1= Yes |
|
|
2= No, not indicated/refused |
|
|
3= No, clinic does not administer/offer MPX vaccination |
|
|
9= Not captured |
|
|
A response of 9 indicates the information is not captured or collected by the facility or is not provided to SSuN. Null values are allowed if the information is collected by the facility but is unknown for this record. |
|
|
|
63.2 |
F1_GCtx |
Was patient prescribed antimicrobials for gonorrhea treatment? |
|
|
1= Yes |
|
|
2= No, not indicated/refused |
|
|
9= Not captured |
|
|
|
63.3 |
F1_CTtx |
Was patient prescribed antimicrobials for chlamydia treatment? |
|
|
1= Yes |
|
|
2= No, not indicated/refused |
|
|
9= Not captured |
|
|
|
|
|
|
|
|
|
|
Data Element Name |
Description/Response Coding |
|
Diagnosis Dataset |
|
|
|
|
64 |
F2_PatientID |
Unique patient identification number assigned by site |
|
|
Will be a secondary key for merging diagnosis and visit record data; should correspond to F1_PatientID. This patient ID should be supplied by the site and may be an person ID assigned at the clinic level. This data element MUST NOT be ‘null’ or contain missing values. |
|
|
|
65 |
F2_Eventid |
Unique visit identification |
|
|
Will be a secondary key for merging diagnosis and visit record data; should correspond to F1_Eventid. This record ID should be supplied by the site and may be an event or visit ID assigned at the clinic level. This data element MUST NOT be ‘null’ or contain missing values except if a treatment record exists independant of a visit. |
|
|
|
66 |
F2_Visdate |
Date of clinic visit |
|
|
Will be a secondary key for merging diagnosis and visit record data; should correspond to F1_Visdate. This data element MUST NOT be ‘null’ or contain missing values except if a treatment record exists independent of a visit. |
|
|
|
67 |
F2_DXCODE |
Diagnosis Code |
|
|
SY01=Syphilis, primary |
|
|
SY02=Syphilis, secondary |
|
|
SY03=Syphilis, early latent |
|
|
SY04=Syphilis, late latent/Unknown |
|
|
SY05=Syphilis, neurosyphilis |
|
|
SY06=Syphilis, unspecified/other |
|
|
GC01=Gonorrhea |
|
|
CT01=Chlamydia |
|
|
GW01=Genital Warts |
|
|
HI01=HIV/AIDS |
|
|
BV01=Bacterial vaginosis (BV) |
|
|
TR01=Trichomoniasis |
|
|
GH01=Genital Herpes |
|
|
NU01=Nongonococcal Urethritis (NGU) |
|
|
MC01=Muco-purulent cervicitis (MPC) |
|
|
MG01=Mycoplasma genitalium |
|
|
PI01=Pelvic Inflammatory Disease (PID) |
|
|
EP01=Epididymitis |
|
|
CC01=Chancroid |
|
|
LV01=Lymphogranuloma venereum (LGV) |
|
|
GI01=Granuloma Inguinale |
|
|
CD01=Candidiasis |
|
|
SC01=Scabies |
|
|
PD01=Pediculosis |
|
|
MPX1=MPX(Suspected) |
|
|
MPX2=MPX(Probable) |
|
|
MPX3=MPX(Confirmed) |
|
|
CS01=Contact to STD |
|
|
PG01=Pregnancy |
|
|
NE01=Normal exam/diagnosis |
|
|
OT01=Other |
|
|
Null values allowed if information is collected by the facility but unknown for this record. |
|
|
|
|
Data Element Name |
Description/Response Coding |
|
Laboratory Dataset |
|
|
|
|
68 |
F3_PatientID |
Unique patient identification number assigned by site |
|
|
Will be a secondary key for merging with laboratory and visit record data; should correspond to F1_PatientID. This patient ID should be supplied by the site and may be an person ID assigned at the clinic level. This data element MUST NOT be ‘null’ or contain missing values. |
|
|
|
69 |
F3_Eventid |
Unique visit identification |
|
|
Will be a secondary key for merging laboratory and visit record data ; should correspond to F1_Eventid. This record ID should be supplied by the site and may be an event or visit ID assigned at the clinic level. This data element MUST NOT be ‘null’ or contain missing values except in the cases of HIV eHARS lab match records (in which case the variable F3_SpecColdate will not be equal to F3_visdate). |
|
|
|
69.1 |
F3_Source |
Did lab record originate from eHARS match? |
|
|
Default to 0 for records NOT coming from the eHARS registry, 1 for lab data from eHARS |
|
|
|
70 |
F3_Visdate |
Date of clinic visit |
|
|
Will be a secondary key for merging laboratory and visit record data; should correspond to F1_Visdate. This data element MUST NOT be ‘null’ or contain missing values except in the cases of HIV eHARS lab match records (in which case the variable F3_SpecColdate will not be equal to F3_visdate. |
|
|
|
71 |
F3_SpecColdate |
Date of specimen collection for this laboratory observation |
|
|
Date the laboratory specimen was collected. Specimen collection date in many cases will be the same as F3_visdate; however it can be different in the case of HIV eHARS lab records since they may be collected independant of the clinic visit. This data element MUST NOT be ‘null’ or contain missing values. |
|
|
|
72 |
F3_Condtested |
What condition was the patient tested for? |
|
|
1 = Syphilis |
|
|
2 = Gonorrhea |
|
|
3 = Chlamydia |
|
|
4 = Chancroid |
|
|
5 = Trichomoniasis |
|
|
6 = HIV/AIDS |
|
|
7 = Bacterial vaginosis |
|
|
8 = Herpes |
|
|
9= Mycoplasm genitalium |
|
|
20 = Pregnancy |
|
|
Although a null value is allowed, sites should make every attempt to make sure the value is not a null value. A record for a lab condition not included in the list above, should not be submitted. |
|
|
|
73 |
F3_Anatsite |
What anatomic site was tested? |
|
|
1 = Urethral |
|
|
2 = Vaginal/cervical |
|
|
3 = Urine |
|
|
4 = Rectal |
|
|
5 = Pharynx |
|
|
6 = Blood |
|
|
8 = Other |
|
|
9= Not captured |
|
|
Although a null value is allowed, sites should make every attempt to make sure the value is not a null value. |
|
|
|
74 |
F3_Test_Type |
What type of test was used? (Will be expanded, recoded) |
|
|
1=Culture |
|
|
2=NAAT |
|
|
3=Non-amplified nucleic acid test/DNA probe |
|
|
4=Gram Stain |
|
|
5=DFA |
|
|
6=Rapid HIV |
|
|
7=ELISA |
|
|
8=Western blot (deprecated code, see 27, 28 below) |
|
|
9=Pooled RNA |
|
|
10=RPR |
|
|
11=VDRL |
|
|
12=FTA |
|
|
13=TP-PA |
|
|
14=MHA |
|
|
15=Wet Mount/Clue Cell |
|
|
16=PH |
|
|
17=Other, not listed |
|
|
18=Unknown |
|
|
22=HIV-1 IA (EIA or Other) |
|
|
23=HIV-1/2 IA (EIA or Other) |
|
|
24=HIV-2 IA (EIA or Other) |
|
|
25=HIV-1/2 Ag/Ab (4th generation) |
|
|
26=HIV-1/2 Type-Differentiating Immunoassay (4th generation) |
|
|
27=HIV-1 Western Blot |
|
|
28=HIV-2 Western Blot |
|
|
29=HIV-1 IFA |
|
|
30=HIV-1 Culture |
|
|
31=HIV-2 Culture |
|
|
32=HIV-1 p24 Antigen |
|
|
33=HIV-1 RNA/DNA NAAT (Qualitative) |
|
|
34=HIV-2 RNA/DNA NAAT (Qualitative) |
|
|
35=HIV-1 RNA/DNA NAAT (Quantitative viral load) |
|
|
36=HIV-2 RNA/DNA NAAT (Quantitative viral load) |
|
|
37=CD4 T-lymphocytes |
|
|
38=CD4 Percent |
|
|
39=HIV-1 Genotype (PR Nucleotide Sequence) |
|
|
40=HIV-1 Genotype (RT Nucleotide Sequence) |
|
|
41=HIV-1 Genotype (PR/RT Nucleotide Sequence) |
|
|
42=HIV-1 Genotype (IN Nucleotide Sequence) |
|
|
43=HIV-1 Genotype (PR/RT/IN Nucleotide Sequence) |
|
|
44=STARHS (BED) |
|
|
45=STARHS (Vironostika-LS) |
|
|
46=STARHS ( BIO-RAD AVIDITY) |
|
|
47=STARHS (Other) |
|
|
48=STARHS (Unknown) |
|
|
49=Rapid (Retired) |
|
|
50=HIV-1/2 Ag/Ab-Distinguishing Immunoassay |
|
|
51=HIV-1 Genotype (EN Nucleotide Sequence) |
|
|
52=HIV-1 Genotype (FI Nucleotide Sequence) |
|
|
53=HIV-1/2 Ag/Ab and Type-Differentiating Immunoassay |
|
|
54=HIV-1/2 Ag/Ab and Type-Differentiating IA - HIV-1 p24 Antigen Analyte |
|
|
55=HIV-1/2 Ag/Ab and Type-Differentiating IA - HIV-1 Antibody Analyte |
|
|
56=HIV-1/2 Ag/Ab and Type-Differentiating IA - HIV-2 Antibody Analyte |
|
|
57=HIV-1/2 Type-Differentiating Immunoassay (Supplemental) |
|
|
58=HIV-1/2 Type-Differentiating IA (Suppl) - HIV-1 Antibody Analyte |
|
|
59=HIV-1/2 Type-Differentiating IA (Suppl) - HIV-2 Antibody Analyte |
|
|
60=HIV-1 Genotype (Unspecified) |
|
|
61=WB/IFA-Legacy |
|
|
62=RIPA-Legacy |
|
|
63=Latex Ag-Legacy |
|
|
64=Peptide-Legacy |
|
|
65=Rapid-Legacy |
|
|
66=Iga-Legacy |
|
|
67=IVAP-Legacy |
|
|
68=Other HIV Antibody-Other-Legacy |
|
|
69=Other HIV Antibody-Unspecified-Legacy |
|
|
70=Viral Load-Other-Legacy |
|
|
71=Viral Load-Unspecified-Legacy |
|
|
72=HIV Detection/Antigen/Viral Load-Other-Legacy |
|
|
73=HIV Detection/Antigen/Viral Load-Unspecified-Legacy |
|
|
74=Syphilis EIA test |
|
|
75=T. Vaginalis Rapid Test |
|
|
76=T. Vaginalis NAAT |
|
|
80=Pregnancy |
|
|
81=T. Vaginalis Culture |
|
|
88= Other |
|
|
99=Not captured |
|
|
Although a null value is allowed, sites should make every attempt to make sure the value is not a null value. |
|
|
|
75 |
F3_Qualres |
What was the qualitative test result? |
|
|
0 = Negative |
|
|
1 = Positive |
|
|
2 = Nonreactive |
|
|
3 = Reactive |
|
|
4 = Indeterminate/equivocal |
|
|
5=Unknown/no result |
|
|
6 = QNS/Contaminated/Unsaturated |
|
|
8 = Other/pending |
|
|
9=Not captured |
|
|
10= Gram Stain Only: Gram-negative intracellular diplococci (GNID) |
|
|
11=Gram Stain Only: ≥2 WBCs / high power field without GNID |
|
|
12= Gram Stain Only: NGU with <2WBC and no GNID |
|
|
13= Gram Stain Only: negative results |
|
|
Although a null value is allowed, sites should make every attempt to make sure the value is not a null value. |
|
|
|
76 |
F3_Quantres |
Numeric - or Ratio (for RPR/VDRL, e.g. 1:2, 1:4, etc.) |
|
|
|
77 |
F3_QuantUnits |
Units for quantitative results: |
|
|
1=Copies/mL |
|
|
2=Log Copies/mL |
|
|
3=Cells/Cubic mm |
|
|
4=CD4% |
|
|
5=Titer Ratio |
|
|
6=Cycles/Time (rtPCR) |
|
|
|
DE # |
Data Element Name |
Description/Response Coding |
|
Treatment Dataset |
|
|
|
|
78 |
F4_PatientID |
Unique patient identification number assigned by site |
|
|
Will be a secondary key for merging treatment and visit record data; should correspond to F1_PatientID. This patient ID should be supplied by the site and may be an person ID assigned at the clinic level. This data element MUST NOT be ‘null’ or contain missing values. |
|
|
|
79 |
F4_Eventid |
Unique visit identification |
|
|
Will be a secondary key for merging treatment and visit record data; should correspond to F1_EventID. This record ID should be supplied by the site and may be an event or visit ID assigned at the clinic level. This data element MUST NOT be ‘null’ or contain missing values except in the case where treatment date (f4_TxDate) is different from F4_Visdate. |
|
|
|
80 |
F4_Visdate |
Date of clinic visit |
|
|
Will be a secondary key for merging treatment and visit record data; should not be ‘null’ or contain missing values except in the case where treatment date (f4_TxDate) is different from F4_Visdate. |
|
|
|
81 |
F4_TxDate |
Treatment Date |
|
|
Date the treatment was dispensed or prescribed. Treatment date in many cases will be the same as F4_visdate; however it can be different if treatment was provided independant of the clinic visit. This data element MUST NOT be ‘null’ or contain missing values. |
|
|
|
82 |
F4_Medication |
What medication was prescribed to the patient (brand name)? |
|
|
1=Penicillin G (benzathine, aqueous procaine, or aqueous crystalline) |
|
|
2=Probenacid |
|
|
10= Amoxicillin (Amoxil, Polymox, Trimox, Wymox) |
|
|
11= Ampicillin (Omnipen, Polycillin, Polycillin-N, Principen, Totacillin) |
|
|
20= Azithromycin (Zithromax) |
|
|
21= Erythromycin base |
|
|
22= Clindamycin (Cleocin) |
|
|
23= Gentamicin (Garamycin, G-Mycin, Jenamicin) |
|
|
30= Cefixime (Suprax) |
|
|
31= Ceftizoxime (Cefizox) |
|
|
32= Cefotaxime (Claforan) |
|
|
33= Cefoxitin (Mefoxin) |
|
|
34= Cefpodoxime (Vantin) |
|
|
35= Ceftibuten (Cedax) |
|
|
36= Cefdinir (omnicef) |
|
|
37= Ceftriaxone (Rocephin) |
|
|
38= Cefuroxime (Ceftin, Kefurox, Zinacef, Zinnat) |
|
|
40= Ciprofloxacin (Cipro, Cipro XR, Ciprobay, Ciproxin) |
|
|
41= Levofloxacin (Cravit, Levaquin) |
|
|
42= Moxifloxacin (Avelox, Vigamox) |
|
|
43= Ofloxacin (Floxin, Oxaldin, Tarivid) |
|
|
44= Gemifloxacin (Factive) |
|
|
50= Doxycycline (Doryx, Vibramycin) |
|
|
60= Metronidazole (Flagyl, Helidac, Metizol, Metric 21, Neo-Metric, Noritate, Novonidazol) |
|
|
61= Tinidazole (Tindamax) |
|
|
70= Tenofovir/emtricitabine (Truvada, Descovy) |
|
|
71= Raltegravir (Isentress) |
|
|
72= Dolutegravir (Tivicay) |
|
|
73=Apretude (Cabotegravir) |
|
|
74= Hepatitis B vaccine |
|
|
75= Hepatitis A vaccine |
|
|
76= Doxy PEP |
|
|
88= Other |
|
|
99=Unknown |
|
|
Although a null value is allowed, sites should make every attempt to make sure the value is not a null value. |
|
|
|
83 |
F4_Medication_Oth |
If the patient received a medication other than what is listed above as |
|
|
indicated by response option #88, please provide name of other medication (Free text description of other medication) |
|
|
|
83.1 |
F4_TxMethod |
New Variable to capture method of administrtaion |
|
|
1=PO - oral dosing |
|
|
2=IM - intramuscular |
|
|
3=IV - intravenous/infusion |
|
|
4=Other |
|
|
5=Unknown |
|
|
6=Intravaginal |
|
|
7=Topical |
|
|
|
84 |
F4_Dosage |
What was the dosage of the medication prescribed? |
|
|
1= 100 mg |
|
|
2= 125mg |
|
|
3= 150mg |
|
|
4= 200mg |
|
|
5= 240mg |
|
|
6= 250mg |
|
|
7= 300mg |
|
|
8= 320mg |
|
|
9= 400mg |
|
|
10= 500mg |
|
|
11= 600mg |
|
|
12= 750mg |
|
|
13= 800mg |
|
|
14= 1g |
|
|
15= 2g |
|
|
16= 50 mg |
|
|
17=2.4 Million Units |
|
|
18=7.2 Million Units |
|
|
88= Other |
|
|
99= Not captured |
|
|
A response of 99 indicates the information is not captured or collected by the facility or is not provided to SSuN. Null value allowed if dosage is unknown or missing. |
|
|
|
85 |
F4_Number_doses |
Total number of doses prescribed? |
|
|
Null value allowed if (1) number of total doses is unknown or missing or (2) the information is not captured or collected by the facility or is not provided to SSuN. Sites can either collect number_doses or duration. It is NOT necessary to collect both variables. Refills should not be include in number of doses. |
|
|
|
86 |
F4_Dose_Freq |
What is the frequency of doses? |
|
|
1=one single dose |
|
|
2= twice day |
|
|
3= three times a day |
|
|
4= four times a day |
|
|
8= other |
|
|
9= Not captured |
|
|
A response of 9 indicates the information is not captured or collected by the facility or is not provided to SSuN. Null value allowed if frequency of doses is unknown or missing. |
|
|
|
87 |
F4_Duration |
What duration was the medication prescribed for? |
|
|
1= 1 day |
|
|
2= 3 days |
|
|
3= 5 days |
|
|
4= 7 days |
|
|
5= 10 days |
|
|
6= 14 days |
|
|
8= Other |
|
|
9= Not captured |
|
|
A response of 9 indicates the information is not captured or collected by the facility or is not provided to SSuN. Null value allowed if duration of medication is unknown or missing. |
|
|
|
DE # |
Data Element Name |
Description/Response Coding |
|
Facility Reference Dataset |
|
|
|
|
88 |
F5_Facility_ID |
Unique facility identifier |
|
|
This ID should be supplied by the site and is a unique facility identifier from underlying surveillance systems or may be generated specifically for SSuN. Regardless of source, this ID must be unique and allow for longitudinal tracking of the facility. This data element MUST NOT be ‘null’ or contain missing values. |
|
|
|
89 |
F5_SiteID |
Unique site code |
|
|
BA=Baltimore (Cycle II, Cycle III, Cycle IV) |
|
|
CB=Columbus Ohio (Cycle IV) |
|
|
CA=California (Cycle II, Cycle III, Cycle IV) |
|
|
FL=Florida (Cycle III & Cycle IV) |
|
|
IN=Indiana (Cycle IV) |
|
|
MC=Multnomah County (Cycle III &Cycle IV) |
|
|
NY=New York City (Cycle II, Cycle III, Cycle IV) |
|
|
PH=Philadelphia (Cycle II, Cycle III, Cycle IV) |
|
|
SF=San Francisco (Cycle II, Cycle III, Cycle IV) |
|
|
WA=Washington (Cycle II, Cycle III, Cycle IV) |
|
|
UT=UTAH (Cycle IV) |
|
|
LA=Louisana (Cycle II) |
|
|
VA=Virginia (Cycle II) |
|
|
AL=Alabama (Cycle II) |
|
|
CO=Colorado (Cycle II) |
|
|
CH=Chicago (Cycle II) |
|
|
MA=Massachusetts (Cycle III) |
|
|
MN=Minnesota (Cycle III) |
|
|
This data element MUST NOT be ‘null’ or contain missing values. |
|
|
|
90 |
F5_Facility_name |
What is the name of the facility? |
|
|
This data element MUST NOT be ‘null’ or contain missing values. |
|
|
|
91 |
F5_Facility_type |
What is the facility type? |
|
|
1= STD clinic |
|
|
88= Other |
|
|
|
92 |
F5_FQHC |
Is this facility a FQHC? |
|
|
1= Yes |
|
|
2= No |
|
|
|
|
|
|
93 |
F5_Facility_Address |
What is the physical street address of the facility? |
|
|
|
94 |
F5_Facility_City |
In what city is the facility located? |
|
|
FIPS code, example: 3290 (City of SF) |
|
|
|
95 |
F5_Facility_State |
In what state is the facility located? |
|
|
FIPS code |
|
|
|
96 |
F5_Facility_Zip |
Zip code for the facility (9-digit ZIP code of facility) |
|
|
|
97 |
F5_Point_contact |
Point of contact at facility |
|
|
|
98 |
F5_EPT |
Does the facility have written policies governing expediated partner therapy? |
|
|
1= Yes |
|
|
2= No |
|
|
9= Facility does not provide/prescribe/test |
|
|
|
99 |
F5_PrEP |
Does the facility have written policies governing referral or management of PrEP? |
|
|
1= Yes |
|
|
2= No |
|
|
3= facility does not refer to or manage PrEP |
|
|
|
100 |
F5_PrEP_Rx |
Does the facility prescribe PrEP? |
|
|
1= Yes |
|
|
2= No |
|
|
|
101 |
F5_PEP_Rx |
Does the facility prescribe PEP? |
|
|
1= Yes |
|
|
2= No |
|
|
|
102 |
F5_PrEP_Manage |
Does the facility actively manage patients on PrEP? |
|
|
1= Yes |
|
|
2= No |
|
|
|
103 |
F5_HPV_vaccine |
Does the facility have written policies governing HPV vaccination? |
|
|
1= Yes |
|
|
2= No |
|
|
9= Facility does not provide/prescribe/test |
|
|
|
104 |
F5_HIV_algorithm |
Does the facility have written policies governing HIV testing? |
|
|
1= Yes |
|
|
2= No |
|
|
3= Facility does not provide/prescribe/test |
|
|
|
105 |
F5_Screening_CT |
Does the facility have written policies governing chlamydia screening? |
|
|
1= Yes |
|
|
2= No |
|
|
3= Facility does not provide/prescribe/test |
|
|
|
106 |
F5_Screening_GC |
Does the facility have written policies governing gonorrhea screening? |
|
|
1= Yes |
|
|
2= No |
|
|
3= Facility does not provide/prescribe/test |
|
|
|
107 |
F5_Billing |
Does the facility bill for STD services? |
|
|
1= Yes |
|
|
2 = No |
|
|
9= Not captured |
|
|
|
108 |
F5_Medical_record |
Type of medical record system? |
|
|
1= paper-based |
|
|
2= electronic |
|
|
3=combination |
|
|
9= not sure |
|
|
|
109 |
F5_Insurance |
Is the facility in an insurance network? |
|
|
1=Yes |
|
|
2=No |
|
|
|
Clinic Patient Survey |
||
110 |
FS1_FirstVis |
First visit at clinic? |
|
|
|
|
|
1=Yes |
|
|
2=No |
|
|
|
111 |
FS1_Welcome |
Do you feel that this clinic provides a welcoming and respectful environment? |
|
|
|
|
|
1=Yes |
|
|
2=No |
|
|
3=Not Sure |
|
|
|
|
|
What are the reasons for your visit to this clinic today (choose all that apply)? |
|
|
Code Below |
112 |
FS1_Reas1 |
Health problem or symptoms |
|
|
|
|
|
1=Yes |
|
|
2=No |
|
|
|
113 |
FS1_Reas2 |
No health problems or symptoms, but came to get STD screening/check-up |
|
|
|
|
|
1=Yes |
|
|
2=No |
|
|
|
114 |
FS1_Reas3 |
Told to get checked by partner |
|
|
|
|
|
1=Yes |
|
|
2=No |
|
|
|
115 |
FS1_Reas4 |
Referred by health department/disease intervention specialist (DIS) |
|
|
|
|
|
1=Yes |
|
|
2=No |
|
|
|
116 |
FS1_Reas5 |
Follow-up visit |
|
|
|
|
|
1=Yes |
|
|
2=No |
|
|
|
117 |
FS1_Reas6 |
Came to get STD test results |
|
|
|
|
|
1=Yes |
|
|
2=No |
|
|
|
118 |
FS1_Reas7 |
Came to get HIV test |
|
|
|
|
|
1=Yes |
|
|
2=No |
|
|
|
119 |
FS1_Reas8 |
Came to get medication that I can take every day to prevent getting HIV infection before I am exposed to the virus (PrEP) |
|
|
|
|
|
1=Yes |
|
|
2=No |
|
|
|
120 |
FS1_Reas9 |
Came to get medication that I can take right away because I think I was exposed to HIV in the past few days (PEP) |
|
|
|
|
|
1=Yes |
|
|
2=No |
|
|
|
121 |
FS1_Reas10 |
Came to get contraception |
|
|
|
|
|
1=Yes |
|
|
2=No |
|
|
|
122 |
FS1_Reas11 |
Some other reason |
|
|
|
|
|
1=Yes |
|
|
2=No |
|
|
|
123 |
FS1_Reas12_TXT |
Specify ____________________ |
|
|
|
124 |
FS1_ReasThisClin |
What is the main reason you chose this clinic for care (choose only one)? |
|
|
1=Could walk in or get same day appointment |
|
|
2=Cost |
|
|
3=Privacy concern |
|
|
4=Expert care |
|
|
5=Embarrassed to go to usual doctor |
|
|
6=Some other reason |
|
|
|
125 |
FS1_ReasThisClin_TXT |
Please specify other reason ______________________ |
|
|
|
126 |
FS1_WhereElse |
Where would you have gone today if this STD clinic did not exist (choose only one)? |
|
|
|
|
|
1=I would have waited to see how I felt and then decided what to do |
|
|
2=Community health center |
|
|
3=Public clinic/ health department clinic |
|
|
4=Family planning clinic |
|
|
5=Private doctor’s office |
|
|
6=Urgent care clinic/walk in clinic |
|
|
7=Hospital emergency room (ER) |
|
|
8=Hospital outpatient department |
|
|
9=School-based clinic |
|
|
10=Some other place |
|
|
|
127 |
FS1_WhereElse_TXT |
Please specify other place ______________________ |
|
|
|
128 |
FS1_UsualPlace |
Is there a place that you USUALLY go to when you are sick or need advice about your health? |
|
|
|
|
|
1=Yes |
|
|
2=No |
|
|
|
129 |
FS1_MostOftenGo |
If YES, what kind of place do you go to most often (choose only one)? |
|
|
|
|
|
1=Community health center |
|
|
2=Public clinic/health department clinic |
|
|
3=Family planning clinic |
|
|
4=Private doctor’s office |
|
|
5=Urgent care clinic/walk in clinic |
|
|
6=Hospital emergency room (ER) |
|
|
7=Hospital outpatient department |
|
|
8=School-based clinic |
|
|
9=Some other place |
|
|
|
130 |
FS1_MostOftenGo_TXT |
Please specify ________________________ |
|
|
|
131 |
FS1_PrevCare |
Is there a place you USUALLY go to when you need routine care or preventive care such as a physical exam or check-up? |
|
|
|
|
|
1=Yes |
|
|
2=No |
|
|
|
132 |
FS1_PrevCareGo |
If YES, what kind of place do you go to most often (choose only one) |
|
|
|
|
|
1=Community health center |
|
|
2=Public clinic/health department clinic |
|
|
3=Family planning clinic |
|
|
4=Private doctor’s office |
|
|
5=Urgent care clinic/walk in clinic |
|
|
6=Hospital emergency room (ER) |
|
|
7=Hospital outpatient department |
|
|
8=School-based clinic |
|
|
9=Some other place |
|
|
|
133 |
FS1_PrevCareGo_TXT |
Please specify ________________________ |
|
|
|
134 |
FS1_Insurance |
Do you have health insurance (choose only one)? |
|
|
|
|
|
1=Yes, parents’ insurance plan |
|
|
2=Yes, government (Medicaid, Medicare, etc.) |
|
|
3=Yes, private insurance (through employer) |
|
|
4=Yes, private insurance (purchased by yourself/healthcare.gov exchange) |
|
|
5=No coverage of any type à GO TO QUESTION # 13 |
|
|
6=Don’t know à GO TO QUESTION # 13 |
|
|
|
135 |
FS1_UseIns |
If YES, would you be willing to use your health insurance for today’s visit? |
|
|
|
|
|
1=Yes |
|
|
2=No |
|
|
|
|
|
If No, why not (choose all that apply)? |
|
|
|
136 |
FS1_NOTUseIns1 |
I do not want my insurance company to know |
|
|
|
|
|
1=Yes |
|
|
2=No |
|
|
|
137 |
FS1_NOTUseIns2 |
Insurance company might send records home |
|
|
|
|
|
1=Yes |
|
|
2=No |
|
|
|
138 |
FS1_NOTUseIns3 |
I do not want my parents/spouse/significant other to know |
|
|
|
|
|
1=Yes |
|
|
2=No |
|
|
|
|
|
|
139 |
FS1_NOTUseIns4 |
Usual doctor might send records home |
140 |
FS1_NOTUseIns5 |
I cannot afford to pay the co-pay or deductible |
141 |
FS1_NOTUseIns6 |
My insurance will not cover this visit |
142 |
FS1_NOTUseIns7 |
Some other reason |
143 |
FS1_NOTUseIns_TXT |
Please specify |
|
|
|
144 |
FS1_BirthSex |
What sex were you assigned at birth on your original birth certificate? |
|
|
|
|
|
1=Male |
|
|
2=Female |
|
|
3=Refused |
|
|
4=Don't know |
|
|
|
145 |
FS1_GendID |
How do you currently describe yourself? |
|
|
|
|
|
1=Male |
|
|
2=Female |
|
|
3=Trans, Male to Female |
|
|
4=Trans, Female to Male |
|
|
5=TG Unknown or Unspecified |
|
|
6=Gender Queer/Non-Binary |
|
|
7=Other |
|
|
|
146 |
FS1_Age |
How old are you? Age in years______ |
|
|
|
147 |
FS1_HispEth |
Do you consider yourseld Hispanic/Latino/a? |
|
|
|
|
|
1=Yes, Hispanic |
|
|
2=No, Not Hispanic |
|
|
8=Unknown/Can't guess |
|
|
9=Refused |
|
|
|
|
|
What is your race (choose all that apply)? |
148 |
FS1_RaceWhite |
White |
|
|
|
|
|
1=Yes |
|
|
2=No |
|
|
|
149 |
FS1_RaceBlack |
Black |
|
|
|
|
|
1=Yes |
|
|
2=No |
|
|
|
150 |
FS1_RaceAIAN |
AI/AN |
|
|
|
|
|
1=Yes |
|
|
2=No |
|
|
|
151 |
FS1_RaceAsian |
ASIAN |
|
|
|
|
|
1=Yes |
|
|
2=No |
|
|
|
152 |
FS1_RaceNHOPI |
NH/OPI |
|
|
|
|
|
1=Yes |
|
|
2=No |
|
|
|
153 |
FS1_RaceOther |
Other race |
|
|
|
|
|
1=Yes |
|
|
2=No |
|
|
|
154 |
FS1_RaceUnk |
Unknown/Can't guess |
|
|
|
|
|
1=Yes |
|
|
2=No |
|
|
|
155 |
FS1_RaceRef |
Refused Race |
|
|
|
|
|
1=Yes |
|
|
2=No |
|
|
|
156 |
FS1_SexOrient |
Which of the following best represents how you think of yourself? |
|
|
|
|
|
1=Heterosexual/Straight |
|
|
2=Gay/Lesbian/Homosexual |
|
|
3=Bisexual |
|
|
4=Other |
|
|
5=I don't know |
|
|
9=Refused |
|
|
|
|
|
What is your current employment status (choose all that apply)? |
|
|
|
157 |
FS1_Employ1 |
Full-time employment |
|
|
|
|
|
1=Yes |
|
|
2=No |
|
|
|
158 |
FS1_Employ2 |
Part-time employment |
|
|
|
|
|
1=Yes |
|
|
2=No |
|
|
|
159 |
FS1_Employ3 |
Unemployed |
|
|
|
|
|
1=Yes |
|
|
2=No |
|
|
|
160 |
FS1_Employ4 |
Disabled |
|
|
|
|
|
1=Yes |
|
|
2=No |
|
|
|
161 |
FS1_Employ5 |
Student |
|
|
|
|
|
1=Yes |
|
|
2=No |
|
|
|
162 |
FS1_Employ6 |
Other |
|
|
|
|
|
1=Yes |
|
|
2=No |
|
|
|
163 |
FS1_Educate |
What is your highest level of school you have completed or the highest degree you have received |
|
|
1=Middle school |
|
|
2=Some high school |
|
|
3=High school diploma |
|
|
4=GED or equivalent |
|
|
5=Some college |
|
|
6=College degree or higher |
|
|
|
Strategy B - Case-based Enhanced Surveillance |
||
|
Data Element Name |
Description |
164 |
P1_SiteID |
|
|
|
This 2 character code primarily identifies sites funded under SSuN Cycle 2 & 3 and will include additional sites as required for Cycle 4. This data element MUST NOT be ‘null’ or contain missing values. |
|
|
BA=Baltimore (Cycle II, Cycle III, Cycle IV) |
|
|
CB=Columbus (Cycle IV) |
|
|
CA=California (Cycle II, Cycle III, Cycle IV) |
|
|
FL=Florida (Cycle III & Cycle IV) |
|
|
IN=Indiana (Cycle IV) |
|
|
MC=Multnomah County (Cycle III &Cycle IV) |
|
|
NY=New York City (Cycle II, Cycle III, Cycle IV) |
|
|
PH=Philadelphia (Cycle II, Cycle III, Cycle IV) |
|
|
SF=San Francisco (Cycle II, Cycle III, Cycle IV) |
|
|
WA= Washington (Cycle II, Cycle III, Cycle IV) |
|
|
UT=UTAH (Cycle IV) |
|
|
LA=Louisana (Cycle II) |
|
|
VA=Virginia (Cycle II) |
|
|
AL=Alabama (Cycle II) |
|
|
CO=Colorado (Cycle II) |
|
|
CH=Chicago (Cycle II) |
|
|
MA=Massachusetts (Cycle III) |
|
|
MN=Minnesota (Cycle III) |
|
|
|
165 |
P1_EventID |
Site generated unique event identifier |
|
|
This record ID should be supplied by the site and may be an event or report identifier from underlying surveillance system. Regardless of source, this ID must be unique for each confirmed case report. This data element MUST NOT be ‘null’ or contain missing values. |
|
|
|
166 |
P1_PatientID |
Site generated ID allows for longitudinal tracking of unique persons |
|
|
This ID should be supplied by the site and may be a unique patient identifier from underlying surveillance systems or may be generated specifically for SSuN from identifying information provided through case reporting. Regardless of source, this ID must be unique and allow for longitudinal tracking of persons reported with multiple episodes of disease. This data element MUST NOT be ‘null’ or contain missing values. |
|
|
|
167 |
P1_RecRepDte |
Earliest date this specific disease event/report received at health department? |
|
|
This date should reflect the earliest information available to the health department regarding the case. This date should include laboratory records received if lab results were reported prior to receipt of a provider case report. This data element MUST NOT be ‘null’ or contain missing values. This should be coded as a ‘SAS’ numeric date. |
|
|
|
168 |
P1_DxDte |
What is the diagnosis date for the current episode of disease (may be date of provider visit, specimen collection date, laboratory report date or other suitable proxy) |
|
|
This data element should not be ‘null’ or contain missing values. This should be coded as a ‘SAS’ numeric date. |
|
|
|
169 |
P1_DxCode |
Diagnosis |
|
|
This data element should not be ‘null’ or contain missing values. For this cycle of SSuN, only values for gonorrhea and for syphilis (10280 and 10311, 10312, 10313 and 10320 are acceptable) |
|
|
|
|
|
10273=Chancroid |
|
|
10274=Chlamydia |
|
|
10280=Gonorrhea |
|
|
10311=Syphilis, primary |
|
|
10312=Syphilis, secondary |
|
|
10313=Syphilis, early non-primary non-secondary |
|
|
10320=Syphilis, unknown duration or late |
|
|
|
170 |
P1_RandSamp |
Is this record/case selected in the random sample? |
|
|
This data element MUST NOT be ‘null’ or contain missing values. (Note: both gonorrhea and syphilis records should be sampled) |
|
|
|
|
|
0=Not in random sample |
|
|
1=In random sample |
|
|
|
171 |
P1_SampDte |
Date record/case sampled by jurisdiction |
|
|
For jurisdiction deploying a batch process for record sampling, this should be the actual date that the batch was sampled. For jurisdictions deploying real-time sampling of cases through their surveillance system, this date should match the report date (or date case status was confirmed if appropriate). This data element should not be ‘null’ or contain missing values. This should be coded as a ‘SAS’ numeric date. |
|
|
|
|
|
|
|
|
|
174 |
P1_InitSx |
If patient previously reported, what is the registry/source of earliest report for this PATIENT? (If the patient was not known to have been previously reported for any disease/condition, this data element may be coded as '.'/Null) |
|
|
|
|
|
0=STD Registry |
|
|
1=HIV Registry |
|
|
2=Viral Hepatitis Registry |
|
|
3=Other Disease Registry |
|
|
4=Unknown |
|
|
|
175 |
P1_HregMatch |
Was eHARS registry match done for this patient? |
|
|
This data element may be initially coded as ‘2’ if the grantee conducts a periodic batch match with their HIV registry and the case is reported before that batch is processed. This information can be updated in the SSuN record in the next data transmission following the match. This data element should not be ‘null’ or contain missing values. |
|
|
1=Yes |
|
|
2=No |
|
|
|
176 |
P1_HregMatchStat |
Did this patient match a registry entry in eHARS? |
|
|
This data element may be initially coded as ‘3’ if the grantee conducts a periodic batch match with their HIV registry and the case is reported before that batch is processed. This information can be updated in the SSuN record in the next data transmission following the match. This data element should not be ‘null’ or contain missing values. |
|
|
|
|
|
1=Matching Record Found |
|
|
2=No Matching Record |
|
|
3=Match Not Performed |
|
|
|
177 |
P1_HregID |
Unique record number from HIV registry (such as stateno from eHARS). |
|
|
This data element should not be ‘null’ or contain missing values if a matching record is present in eHARS. Sites may decide to use a locally generated UNIQUE registry number rather than STATENO as long as this number can be used to obtain matching HIV laboratory data) |
|
|
|
178 |
P1_HDXMOYR |
What is this patient's earliest indication of HIV positive result? |
|
|
This information can be obtained from the eHARS person table (HIVPMOYR). If eHARS match found. This should be coded as character data (“MM/YY”) with missing information as “../..” or “../YY” |
|
|
|
179 |
P1_EXPMOD |
Exposure (HIV transmission) mode from HIV registry. |
|
|
This data element should not be ‘null’ or contain missing values if a matching record is present in eHARS. |
|
|
|
|
|
1=MSM Only |
|
|
2=IDU Only |
|
|
3=Heterosexual Contact Only |
|
|
4=MSM & IDU |
|
|
5=IDU & Heterosexual Contact |
|
|
6=MSM & Heterosexual Contact |
|
|
7=MSM, IDU & Heterosexual Contact |
|
|
8=Perinatal Exposure |
|
|
9=Other/Unknown |
|
|
|
|
|
|
182 |
P1_PrevDx |
Most recent previous diagnosis (if applicable; could include hep, TB or HIV) |
|
|
If this patient also has a record in other/ancillary disease registries as indicated above, indicate the diagnosis documented by that record. Should be ‘Null’ if no previous diagnosis is confirmed. Note that previous gonorrhea diagnoses are captured in DE#184, prioritize non-gonorrhea diagnoses for this data element (HIV, syphilis, CT, etc.) |
|
|
|
|
|
10311=Syphilis, primary |
|
|
10312=Syphilis, secondary |
|
|
10313=Syphilis, early non-primary non-secondary |
|
|
10320=Syphilis, unknown duration or late |
|
|
10280=Gonorrhea |
|
|
10274=Chlamydia |
|
|
10100=Hepatitis B, acute |
|
|
10105=Hepatitis B, chronic |
|
|
20001=Hepatitis C |
|
|
10562=HIV infection (non-AIDS) |
|
|
10560=AIDS |
|
|
10307=Nongonococcal Urethritis (NGU) |
|
|
10308=Muco-purulent cervicitis (MPC) |
|
|
10309=Pelvic Inflammatory Disease (PID) |
|
|
10273=Chancroid |
|
|
10306=Lymphogranuloma venereum (LGV) |
|
|
10276=Granuloma Inguinale |
|
|
20002=TB |
|
|
20003=Other |
|
|
|
183 |
P1_PrevDxDte |
Date of most recent previous diagnosis documented above. |
|
|
Should not be null if P1_PrevDx is not null. |
|
|
|
184 |
P1_PrevGCDx |
Has the patient been previously diagnosed and reported with GC? |
|
|
|
|
|
1=Yes |
|
|
2=No |
|
|
3=Registry records not searched |
|
|
|
185 |
P1_PrevGCDxDte |
Date of most recent previous diagnosis of GC documented above. |
|
|
Should not be null if P1_PrevGCDx = 1. This should be coded as a ‘SAS’ numeric date. |
|
|
|
186 |
P1_ConcurCTDx |
Was this patient diagnosed with CT at the same time as their current GC diagnoses? |
|
|
|
|
|
1=Yes, tested and found to be CT positive |
|
|
2=No, tested and found to be CT negative |
|
|
3=No, patient not tested for CT/No CT information available |
|
|
|
187 |
P1_CaseDup |
Is this record/case a duplicate report, new report or was duplicate status not determined? |
|
|
The grantee should document if an initial case report was subsequently found to be a duplicate of an existing case – the record should be retained in the SSuN dataset and coded as a duplicate (‘1’)? If the jurisdiction receives a report that they know to be a duplicate (same patient/eent in last 28 days) at the time of report, the record can be omitted from the SSuN datasets and not sampled for enhanced investigation. This data element should not be ‘null’ or contain missing values. |
|
|
|
|
|
0=New Case |
|
|
1=Duplicate Case (previously reported in last 28 days) |
|
|
9=Unknown, site surveillance system does not capture |
|
|
|
188 |
P1_FacilityID |
Site generated facility ID. Each reporting provider/facility must have a unique ID. |
|
|
This is a primary key for linking the provider type and other provider information to the case record. Historically, the majority of cases in any grantee’s jurisdictions will be reported from known providers, but for cases reported from entirely new or unknown providers, this field should be populated with that facility’s new number and be included in the next update of the provider reference file. This data element should not be ‘null’ or contain missing values. |
|
|
|
|
|
|
191 |
P1_PtxSex |
Current sex of the patient as indicated on initial health department report? |
|
|
This data element should not be ‘null’ or contain missing values. For transgender individuals, please record the gender direction (e.g. 'male' for a female to male trensgendered patient, if transgender but sex unknown, code as 9: "Unknown") |
|
|
|
|
|
1=Male |
|
|
2=Female |
|
|
9=Unknown |
|
|
|
192 |
P1_PtxGendID |
Gender Identity of the patient as indicated on initial health department report. |
|
|
This data element should not be ‘null’ or contain missing values. If this information is not reported on case or lab report, code as 9: "Gender Identity not documented" |
|
|
1=Male-to-Female Transgender |
|
|
2=Female-to-Male Transgender |
|
|
3=Transgender, not specified |
|
|
4=CIS Gender (Male or Female, NOT transgendered) |
|
|
9=Gender Identity not documented |
|
|
|
193 |
P1_PtxRace_White |
White Race |
|
|
Information from case/lab reports to the health department only. Patient self-report from interviews should be captured in interview variables. If additional information from any source (other than patient report) is received, these data may be updated as required by underlying surveillance system. |
|
|
|
|
|
1=Yes |
|
|
2=No |
|
|
3=Unknown |
|
|
4=Refused |
|
|
|
194 |
P1_PtxRace_Black |
Black Race |
|
|
Information from case/lab reports to the health department only. Patient self-report from interviews should be captured in interview variables. If additional information from any source (other than patient report) is received, these data may be updated as required by underlying surveillance system. |
|
|
|
|
|
1=Yes |
|
|
2=No |
|
|
3=Unknown |
|
|
4=Refused |
|
|
|
195 |
P1_PtxRace_AIAN |
American Indian/Alaska Native Race |
|
|
Information from case/lab reports to the health department only. Patient self-report from interviews should be captured in interview variables. If additional information from any source (other than patient report) is received, these data may be updated as required by underlying surveillance system. |
|
|
|
|
|
1=Yes |
|
|
2=No |
|
|
3=Unknown |
|
|
4=Refused |
|
|
|
196 |
P1_PtxRace_Asian |
Asian Race |
|
|
Information from case/lab reports to the health department only. Patient self-report from interviews should be captured in interview variables. If additional information from any source (other than patient report) is received, these data may be updated as required by underlying surveillance system. |
|
|
|
|
|
1=Yes |
|
|
2=No |
|
|
3=Unknown |
|
|
4=Refused |
|
|
|
197 |
P1_PtxRace_NHOPI |
Native Hawaiian/Other Pacific Islander Race |
|
|
Information from case/lab reports to the health department only. Patient self-report from interviews should be captured in interview variables. If additional information from any source (other than patient report) is received, these data may be updated as required by underlying surveillance system. |
|
|
|
|
|
1=Yes |
|
|
2=No |
|
|
3=Unknown |
|
|
4=Refused |
|
|
|
198 |
P1_PtxRace_Other |
Other Race |
|
|
Information from case/lab reports to the health department only. Patient self-report from interviews should be captured in interview variables. If additional information from any source (other than patient report) is received, these data may be updated as required by underlying surveillance system. |
|
|
|
|
|
1=Yes |
|
|
2=No |
|
|
3=Unknown |
|
|
4=Refused |
|
|
|
199 |
P1_PtxRace_UNK |
Is all information on race and Hispanic ethnicity missing from initial |
|
|
If additional/supplemental information is received on race and ethnicity of patient but this information was missing from the initial report to the health department, please leave this data element coded as ‘1’ and capture the source of supplemental information below. |
|
|
|
|
|
1=Yes |
|
|
2=No |
|
|
|
200 |
P1_PtxRaceSource |
What is the source of the final race information of record as ascertained for this patient? |
|
|
For grantees able to distinguish the source of information for race, please indicate as appropriate. For grantees NOT able to distinguish the source of race data at all, code as ‘6’. If race information is missing/unknown from all sources, code as ‘5’. |
|
|
|
|
|
1=Patient Self-Report |
|
|
2=Provider Case Report |
|
|
3=Laboratory Report |
|
|
4=Previous Registry Record |
|
|
5=No Information Available from Any Source |
|
|
6=Source not Identifiable |
|
|
|
201 |
P1_PtxHisp |
Patient Hispanic ethnicity |
|
|
Information from case/lab reports to the health department only. Patient self-report from interviews should be captured in interview variables. If additional information from any source (other than patient report) is received, these data may be updated as required by underlying surveillance system. |
|
|
|
|
|
1=Hispanic |
|
|
2=Non-Hispanic |
|
|
3=Unknown |
|
|
4=Refused |
|
|
|
202 |
P1_PtxHISPSource |
What is the source of the final Hispanic ethnicity information |
|
|
For grantees able to distinguish the source of information for Hispanic ethnicity, please indicate as appropriate. For grantees NOT able to distinguish the source of Hispanic ethnicity data at all, code as ‘6’. If information is missing/unknown from all sources, code as ‘5’. |
|
|
|
|
|
1=Patient Self-Report |
|
|
2=Provider Case Report |
|
|
3=Laboratory Report |
|
|
4=Previous Registry Record |
|
|
5=No Information Available from Any Source |
|
|
6=Source not Identifiable |
|
|
|
203 |
P1_PtxAGE |
Age of patient from initial reporting record/document . |
|
|
If age information is missing/unknown from all sources, use null value. |
|
|
|
204 |
P1_PtxAgeUnit |
Age unit |
|
|
If #32 is null, use null value for this data element (‘.’) |
|
|
|
|
|
1=Years |
|
|
2=Months |
|
|
|
205 |
P1_PtxCountyres |
County of patient residence |
|
|
If information is missing/unknown, code to null value ( ‘.’) |
|
|
|
206 |
P1_PtxCTract |
Census Tract of patient residence |
|
|
If information is missing/unknown, code to null value (‘.’) |
|
|
|
207 |
P1_PtxAddrStat |
Was patient street address present and complete in initial reporting documents? |
|
|
This data element should not be ‘null’ or contain missing values. |
|
|
|
|
|
1=Street Address Known |
|
|
2=Street Address Missing |
|
|
3=Street Address Incomplete |
|
|
|
208 |
P1_GCAccuracy |
What is the basis of census tract assignment (XY coordinates, street segment, centroid, etc.) |
|
|
This data element should not be ‘null’ or contain missing values. |
|
|
|
|
|
1=Close (based on direct street segment, parcel, or lon/lat match.) |
|
|
2=Approximate (modification of address required to match to to street segment) |
|
|
3=Very approximate (based only on zip or city centroid) |
|
|
4=Not-geocodable (insufficient data to geocode, PO Box, General Delivery) |
|
|
9=Missing (no address available) |
|
|
|
209 |
P1_SiteUrine |
Urine 'site' of infection |
|
|
If information is missing/unknown, code as ‘3’ |
|
|
|
|
|
1=Yes |
|
|
2=No |
|
|
3=Unknown |
|
|
|
210 |
P1_SiteVagCerv |
Vaginal or cervical site of infection in women |
|
|
If information is missing/unknown, code as ‘3’ |
|
|
|
|
|
1=Yes |
|
|
2=No |
|
|
3=Unknown |
|
|
|
211 |
P1_SiteUreth |
Urethral site of infection - only if this is specifically indicated. |
|
|
If information is missing/unknown, code as ‘3’ |
|
|
|
|
|
1=Yes |
|
|
2=No |
|
|
3=Unknown |
|
|
|
212 |
P1_SiteRect |
Rectal site of infection |
|
|
If information is missing/unknown, code as ‘3’ |
|
|
|
|
|
1=Yes |
|
|
2=No |
|
|
3=Unknown |
|
|
|
213 |
P1_SitePhar |
Pharyngeal site of infection |
|
|
If information is missing/unknown, code as ‘3’ |
|
|
|
|
|
1=Yes |
|
|
2=No |
|
|
3=Unknown |
|
|
|
214 |
P1_SiteEye |
Ocular site of infection |
|
|
If information is missing/unknown, code as ‘3’ |
|
|
|
|
|
1=Yes |
|
|
2=No |
|
|
3=Unknown |
|
|
|
215 |
P1_SiteSera |
Blood or sera infection |
|
|
If information is missing/unknown, code as ‘3’ |
|
|
|
|
|
1=Yes |
|
|
2=No |
|
|
3=Unknown |
|
|
|
216 |
P1_SiteJoint |
Joint or synovial fluid infection |
|
|
If information is missing/unknown, code as ‘3’ |
|
|
1=Yes |
|
|
2=No |
|
|
3=Unknown |
|
|
|
217 |
P1_SiteOTH |
Site of infection, not specified above |
|
|
If information is missing/unknown, code as ‘3’ |
|
|
|
|
|
1=Yes |
|
|
2=No |
|
|
3=Unknown |
|
|
|
218 |
P1_SiteUNK |
All site of infection information missing for this case - use only if no other information is available. |
|
|
If the answer to any one of 40-48 above is ‘1’ or ‘2’ then this data element should be coded ‘2’. If all data elements 40-48 are coded as ‘3’ then code this data element as ‘1’. |
|
|
|
|
|
1=Yes |
|
|
2=No |
|
|
|
|
Data elements from provider investigations |
|
219 |
P2_ProvID |
|
|
|
This data element MUST NOT be ‘null’ or contain missing values for cases in the random sample. SHOULD NOT be null for all other cases (collaborators requested to include this information for all gonorrhea case records – this can be accomplished with a default coding of P2_ProvID= P1_FacilityID. |
|
|
|
220 |
P2_ProvCO |
County FIPS code for provider/facility physical location |
|
|
This should be coded as the 3-digit FIPS code for the county. |
|
|
|
221 |
P2_ProvZIP |
Facility/provider physical location 5-digit ZIP |
|
|
|
222 |
P2_ProvCHC |
Is facility/provider a Community Health Center (CHC)? |
|
|
Community Health Centers are not-for-profit primary care organizations governed by a community board and whose primary mission is to provide medical services to traditionally under-served populations. The primary way of determining CHC status is by self-identification (though some put it in their name). The National Association of Community Health Centers (NACHC) does maintain member lists as well. Non-profit and community board governance are the key features. |
|
|
|
|
|
1=Yes |
|
|
2=No |
|
|
3=Unknown |
|
|
|
223 |
P2_ProvFQHC |
Is facility/provider a Federally Qualified Health Center (FQHC)? |
|
|
Federally qualified health centers (FQHCs) include all organizations receiving grants under Section 330 of the Public Health Service Act (PHS). These are a matter of public record and lists are available from HRSA |
|
|
|
|
|
1=Yes |
|
|
2=No |
|
|
3=Unknown |
|
|
|
224 |
P2_ProvPTXvisitDte |
Date of patient initial visit for this issue, can be supplied/filled in from initial case report. |
|
|
This should be formatted as a ‘SAS’ numeric date. |
|
|
|
225 |
P2_ProvClinType |
What was the category of provider examining/treating this patient? |
|
|
|
|
|
1=MD |
|
|
2=RN |
|
|
3=PA |
|
|
4=ARNP |
|
|
5=LPN |
|
|
6=Other |
|
|
7=Unknown/Not Ascertained |
|
|
|
226 |
P2_ProvPTX_GenderSP |
Provider documented gender of sex partners |
|
|
|
|
|
1=Males only |
|
|
2=Females only |
|
|
3=Both Males and Females |
|
|
4=No Sex Partners Last 3 Mos |
|
|
9=Not Captured/Not Documented |
|
|
|
227 |
P2_ProvPTX_Insure |
Insurance status of patient from provider's records |
|
|
|
|
|
1=Yes, Insured |
|
|
2=No, Not Insured |
|
|
3=Unknown |
|
|
|
228 |
P2_Urethritis |
Was urethritis found on exam |
|
|
Missing/unknown information code as null (‘.’). |
|
|
|
|
|
1=Yes |
|
|
2=No |
|
|
|
229 |
P2_Proctitis |
Was proctitis found on exam |
|
|
Missing/unknown information code as null (‘.’). |
|
|
|
|
|
1=Yes |
|
|
2=No |
|
|
|
230 |
P2_Epididymitis |
Was epididymitis found on exam |
|
|
Missing/unknown information code as null (‘.’). |
|
|
|
|
|
1=Yes |
|
|
2=No |
|
|
|
231 |
P2_PID |
Was PID diagnosed. |
|
|
Missing/unknown information code as null (‘.’). |
|
|
|
|
|
1=Yes |
|
|
2=No |
|
|
|
232 |
P2_Discharge |
Was discharge found on exam |
|
|
Missing/unknown information code as null (‘.’). |
|
|
|
|
|
1=Yes |
|
|
2=No |
|
|
|
233 |
P2_OtherFinding |
Were there other STD-related findings on exam |
|
|
Missing/unknown information code as null (‘.’). |
|
|
|
|
|
1=Yes |
|
|
2=No |
|
|
|
234 |
P2_NoFinding |
Were there NO findings on exam |
|
|
Missing/unknown information code as null (‘.’). |
|
|
|
|
|
1=Yes |
|
|
2=No |
|
|
|
235 |
P2_ProvScrnUreth |
Was patient screened/tested for infection at urethral site |
|
|
|
|
|
1=Yes |
|
|
2=No |
|
|
3=Unknown |
|
|
4=Refused |
|
|
|
236 |
P2_ProvScrnVagCerv |
Was patient screened/tested for infection at vaginal/cervical site |
|
|
|
|
|
1=Yes |
|
|
2=No |
|
|
3=Unknown |
|
|
4=Refused |
|
|
|
237 |
P2_ProvScrnAnal |
Was patient screened/tested for infection at anorectal site |
|
|
|
|
|
1=Yes |
|
|
2=No |
|
|
3=Unknown |
|
|
4=Refused |
|
|
|
238 |
P2_ProvScrnPhar |
Was patient screened/tested for infection at pharyngeal site |
|
|
|
|
|
1=Yes |
|
|
2=No |
|
|
3=Unknown |
|
|
4=Refused |
|
|
|
239 |
P2_ProvScrnHIV |
Was patient screened/tested for HIV infection at time of visit |
|
|
|
|
|
1=Yes |
|
|
2=No |
|
|
3=Unknown |
|
|
4=Refused |
|
|
|
|
Treatment Repeating Table (sourced either from initial case report or provider investigations) |
|
|
|
|
240 |
P2_PR_EventID |
Primary key for merging treatment records with case file, should be the same as P1_EventID |
|
|
|
|
|
Must not be missing or null. |
|
|
|
241 |
P2_PR_ProvPTX_TxDte |
Treatment date (or date of administration, date prescription given) |
|
|
This should be coded as a ‘SAS’ numeric date. Missing/unknown information code as null (‘.’). |
|
|
|
242 |
P2_PR_DrugName |
What drug was patient treated with? |
|
|
|
|
|
01=Penicillin G (benzathine, aqueous procaine, or aqueous crystalline) |
|
|
02=Probenacid |
|
|
10= Amoxicillin (Amoxil, Polymox, Trimox, Wymox) |
|
|
11= Ampicillin (Omnipen, Polycillin, Polycillin-N, Principen, Totacillin) |
|
|
20= Azithromycin (Zithromax) |
|
|
21= Erythromycin base |
|
|
22= Clindamycin (Cleocin) |
|
|
23= Gentamicin (Garamycin, G-Mycin, Jenamicin) |
|
|
30= Cefixime (Suprax) |
|
|
31= Ceftizoxime (Cefizox) |
|
|
32= Cefotaxime (Claforan) |
|
|
33= Cefoxitin (Mefoxin) |
|
|
34= Cefpodoxime (Vantin) |
|
|
35= Ceftibuten (Cedax) |
|
|
36= Cefdinir (omnicef) |
|
|
37= Ceftriaxone (Rocephin) |
|
|
38= Cefuroxime (Ceftin, Kefurox, Zinacef, Zinnat) |
|
|
40= Ciprofloxacin (Cipro, Cipro XR, Ciprobay, Ciproxin) |
|
|
41= Levofloxacin (Cravit, Levaquin) |
|
|
42= Moxifloxacin (Avelox, Vigamox) |
|
|
43= Ofloxacin (Floxin, Oxaldin, Tarivid) |
|
|
44= Gemifloxacin (Factive) |
|
|
50= Doxycycline (Doryx, Vibramycin) |
|
|
60= Metronidazole (Flagyl, Helidac, Metizol, Metric 21, Neo-Metric, Noritate, Novonidazol) |
|
|
61= Tinidazole (Tindamax) |
|
|
70= Truvada (Tenofovir/emtricitabine) |
|
|
71=Raltegravir (Isentress) |
|
|
72=Dolutegravir (Tivicay) |
|
|
88= Other (provide text in P2_PR_OthMedTXT) |
|
|
99=Not Captured |
|
|
Must not be missing or null. |
|
|
|
243 |
P2_PR_OthMedTXT |
Other medication if value of 88 selected for P2_PR_DrugName |
|
|
|
244 |
P2_PR_Dosage |
Dosage - numeric |
|
|
Missing/unknown information code as null (‘.’). |
|
|
|
245 |
P2_PR_Dose_Units |
Dosage units |
|
|
|
|
|
01-Miligrams (mg) |
|
|
02-Grams (g) |
|
|
03-Units |
|
|
04-Units/Kilogram |
|
|
05-Million Units |
|
|
06-Million Units/Kilogram |
|
|
07-Milliliters (ml) |
|
|
|
246 |
P2_PR_Method |
Method of administration |
|
|
|
|
|
01=PO - oral dosing |
|
|
02=IM - intramuscular |
|
|
03=IV - intravenous/infusion |
|
|
04=Other |
|
|
05=Unknown |
|
|
Missing/unknown information code as null (‘.’). |
|
|
|
247 |
P2_PR_Number |
Number of doses/day |
|
|
|
|
|
0=Single dose, STAT |
|
|
Numeric value for all other |
|
|
Missing/unknown information code as null (‘.’). |
|
|
|
248 |
P2_PR_Duration_Number |
Days duration or frequency of doses |
|
|
Missing/unknown information code as null (‘.’). |
|
|
|
|
Data elements from provider investigations |
|
249 |
P2_ProvPTX_PDPT |
|
|
|
Missing/unknown information code as null (‘.’). |
|
|
|
|
|
1=Yes |
|
|
2=No |
|
|
|
250 |
P2_ProvPTX_HIBC |
Was patient counseled to prevent transmission/reinfection? |
|
|
Missing/unknown information code as null (‘.’). |
|
|
|
|
|
1=Yes |
|
|
2=No |
|
|
|
250.1 |
P2_ProvPTX_PrepRx |
Was patient prescribed PrEP? |
|
|
|
|
|
1=Yes |
|
|
2=No |
|
|
Missing/unknown information code as null (‘.’). |
|
|
|
250.2 |
P2_ProvPTX_dPEPRx |
Was patient prescribed doxycycline as STI prophylaxis? |
|
|
|
|
|
1=Yes |
|
|
2=No |
|
|
Missing/unknown information code as null (‘.’). |
|
|
|
251 |
P2_ProvPTX_Refer |
Was patient referred to HD (or other) for partner services? |
|
|
Missing/unknown information code as null (‘.’). |
|
|
|
|
|
1=Yes |
|
|
2=No |
|
|
|
252 |
P2_ProvPTX_PrepRefer |
Was patient referred for PrEP? |
|
|
Missing/unknown information code as null (‘.’). |
|
|
|
|
|
1=Yes |
|
|
2=No |
|
|
|
|
Data elements from Patient Interviews |
|
|
|
|
253 |
P3_IDX_ID |
Interviewer/Investigator ID |
|
|
This is a locally assigned ID to uniquely identify the person conducting patient interview. This data element should not be ‘null’ or contain missing values for interviewed cases. |
|
|
|
254 |
P3_PatientID |
Unique identifier for person/patient |
|
|
Will be a secondary key for merging data; should correspond to P1_PatientID. This data element should not be ‘null’ or contain missing values for interviewed cases. |
|
|
|
255 |
P3_EventID |
Unique identifier for record |
|
|
Will be a primary key for merging data; should correspond to P1_EventID. This data element should not be ‘null’ or contain missing values for interviewed cases. |
|
|
|
256 |
P3_IDX_CADate1 |
Contact attempt date 1 |
|
|
This data element should not be ‘null’ or contain missing values for interviewed cases. |
|
|
|
257 |
P3_IDX_CAout1 |
Contact attempt outcome 1 |
|
|
This data element should not be ‘null’ or contain missing values for interviewed cases. |
|
|
|
|
|
0=Answer/Partial or Complete Interview Obtained |
|
|
1=No Answer/No Message |
|
|
2=No Answer/Message Left |
|
|
3=Answer/Hang up |
|
|
4=Answer/Refusal |
|
|
5=Answer/Reschedule DIS call-back |
|
|
6=Answer/Reschedule Patient Callback |
|
|
7=Number out of service |
|
|
8=Other |
|
|
|
258 |
P3_IDX_CADate2 |
Contact attempt date 2 |
|
|
This should be coded as a ‘SAS’ numeric date. |
|
|
|
259 |
P3_IDX_CAout2 |
Contact attempt outcome 2 |
|
|
|
|
|
0=Answer/Partial or Complete Interview Obtained |
|
|
1=No Answer/No Message |
|
|
2=No Answer/Message Left |
|
|
3=Answer/Hang up |
|
|
4=Answer/Refusal |
|
|
5=Answer/Reschedule DIS call-back |
|
|
6=Answer/Reschedule Patient Callback |
|
|
7=Number out of service |
|
|
8=Other |
|
|
|
260 |
P3_IDX_CADate3 |
Contact attempt date 3 |
|
|
This should be coded as a ‘SAS’ numeric date. |
|
|
|
261 |
P3_IDX_CAout3 |
Contact attempt outcome 3 |
|
|
|
|
|
0=Answer/Partial or Complete Interview Obtained |
|
|
1=No Answer/No Message |
|
|
2=No Answer/Message Left |
|
|
3=Answer/Hang up |
|
|
4=Answer/Refusal |
|
|
5=Answer/Reschedule DIS call-back |
|
|
6=Answer/Reschedule Patient Callback |
|
|
7=Number out of service |
|
|
8=Other |
|
|
|
262 |
P3_IDX_CADate4 |
Contact attempt date 4 |
|
|
This should be coded as a ‘SAS’ numeric date. |
|
|
|
263 |
P3_IDX_CAout4 |
Contact attempt outcome 4 |
|
|
|
|
|
0=Answer/Partial or Complete Interview Obtained |
|
|
1=No Answer/No Message |
|
|
2=No Answer/Message Left |
|
|
3=Answer/Hang up |
|
|
4=Answer/Refusal |
|
|
5=Answer/Reschedule DIS call-back |
|
|
6=Answer/Reschedule Patient Callback |
|
|
7=Number out of service |
|
|
8=Other |
|
|
|
264 |
P3_IDX_Ixdate |
Interview/Disposition Date |
|
|
This should be coded as a ‘SAS’ numeric date. |
|
|
|
265 |
P3_IDX_Dispo |
Patient Investigation/Interview Disposition |
|
|
Should not be ‘null’ for cases included in random sample. |
|
|
|
|
|
00=Investigation complete: patient contacted, interview completed |
|
|
01=Investigation complete: patient contacted, partial interview completed |
|
|
10=Investigation not complete: Phase 3 investigation pending |
|
|
11=Investigation not complete: patient contacted, refused interview |
|
|
12=Investigation not complete: patient contacted, unable to complete because of language barrier |
|
|
22=Investigation not complete: patient did not respond to contact attempts |
|
|
33=Investigation not complete: patient contact not initiated because patient resident in correctional, mental health or substance abuse facility |
|
|
44=Investigation not complete: patient contact not initiated because patient is active military on foreign deployment |
|
|
55=Investigation not complete: >60 days from diagnosis |
|
|
66=Investigation not complete: case determined to be OOJ |
|
|
77=Investigation not complete: insufficient contact information |
|
|
88=Investigation not complete: provider refused patient contact |
|
|
99=Investigation not complete: administrative closure/other reason |
|
|
|
266 |
P3_PTX_age |
What is your age? |
|
|
This data element should not be ‘null’ or contain missing values for interviewed cases. May be ‘Null’ (P3_IDX_Dispo) = ‘1’, partial interview. |
|
|
|
|
|
888=Refused |
|
|
|
267 |
P3_PTX_Birthsex |
What was your sex at birth (recorded on your birth certificate)? |
|
|
This data element should not be ‘null’ or contain missing values for interviewed cases. May be ‘Null’ (P3_IDX_Dispo) = ‘1’, partial interview. |
|
|
1= Male |
|
|
2=Female |
|
|
3=Intersex |
|
|
4=Unknown |
|
|
9=Refused |
|
|
|
267.1 |
P3_PTX_GendID |
What gender or sex do you consider yourself to be? |
|
|
|
|
|
1=Male |
|
|
2=Female |
|
|
3=Male-to-Female TG |
|
|
4=Female-to-Male TG |
|
|
5=TG Unspecified |
|
|
6=Queer, Gender Non-binary |
|
|
7=Other |
|
|
8=Refused |
|
|
|
268 |
P3_PTX_HispEthnic |
Do you consider yourself to be Hispanic or Latino/a? |
|
|
This data element should not be ‘null’ or contain missing values for interviewed cases. May be ‘Null’ (P3_IDX_Dispo) = ‘1’, partial interview. |
|
|
|
|
|
1=Yes |
|
|
2=No |
|
|
3=Unknown |
|
|
4=Refused |
|
|
|
|
|
|
271 |
P3_PTX_White |
patient reported White race |
|
|
This data element should not be ‘null’ or contain missing values for interviewed cases. May be ‘Null’ (P3_IDX_Dispo) = ‘1’, partial interview. |
|
|
|
|
|
1=Yes |
|
|
2=No |
|
|
3=Unknown |
|
|
4=Refused |
|
|
|
272 |
P3_PTX_Black |
patient reported Black race |
|
|
This data element should not be ‘null’ or contain missing values for interviewed cases. May be ‘Null’ (P3_IDX_Dispo) = ‘1’, partial interview. |
|
|
|
|
|
1=Yes |
|
|
2=No |
|
|
3=Unknown |
|
|
4=Refused |
|
|
|
273 |
P3_PTX_AIAN |
patient reported AIAN race |
|
|
This data element should not be ‘null’ or contain missing values for interviewed cases. May be ‘Null’ (P3_IDX_Dispo) = ‘1’, partial interview. |
|
|
|
|
|
1=Yes |
|
|
2=No |
|
|
3=Unknown |
|
|
4=Refused |
|
|
|
274 |
P3_PTX_AIAN_TXT |
Tribal Affiliation |
|
|
|
275 |
P3_PTX_Asian |
patient reported Asian race |
|
|
This data element should not be ‘null’ or contain missing values for interviewed cases. May be ‘Null’ (P3_IDX_Dispo) = ‘1’, partial interview. |
|
|
|
|
|
1=Yes |
|
|
2=No |
|
|
3=Unknown |
|
|
4=Refused |
|
|
|
|
|
|
277 |
P3_PTX_NHOPI |
patient reported NHOPI race |
|
|
This data element should not be ‘null’ or contain missing values for interviewed cases. May be ‘Null’ (P3_IDX_Dispo) = ‘1’, partial interview. |
|
|
|
|
|
1=Yes |
|
|
2=No |
|
|
3=Unknown |
|
|
4=Refused |
|
|
|
279 |
P3_PTX_OTHrace |
patient reported other race |
|
|
This data element should not be ‘null’ or contain missing values for interviewed cases. May be ‘Null’ (P3_IDX_Dispo) = ‘1’, partial interview. |
|
|
|
|
|
1=Yes |
|
|
2=No |
|
|
3=Unknown |
|
|
4=Refused |
|
|
|
280 |
P3_PTX_OTHraceTxt |
Patient-reported other race |
|
|
|
|
|
|
281 |
P3_PTX_RefRace |
patient refuses provision of all race information |
|
|
This data element should not be ‘null’ or contain missing values for interviewed cases. May be ‘Null’ (P3_IDX_Dispo) = ‘1’, partial interview. |
|
|
|
|
|
1=Yes |
|
|
2=No |
|
|
|
|
|
|
285 |
P3_PTX_Insure |
Do you have any kind of health care coverage, including health insurance, prepaid plans such as HMOs, or government plans such as Medicare, Indian Health Services, the V.A. or Military? |
|
|
This data element should not be ‘null’ or contain missing values for interviewed cases. May be ‘Null’ (P3_IDX_Dispo) = ‘1’, partial interview. |
|
|
|
|
|
1=Yes |
|
|
2=No |
|
|
3=Don't Know /Don't Remember/ Not Sure |
|
|
4=Refused |
|
|
|
286 |
P3_PTX_InsType |
What kind of healthcare insurance do you have? |
|
|
This data element should not be ‘null’ or contain missing values for interviewed cases. May be ‘Null’ (P3_IDX_Dispo) = ‘1’, partial interview. |
|
|
|
|
|
1=Private healthcare insurance provided by my employer |
|
|
2=Private healthcare insurance I pay for myself |
|
|
3=Public healthcare insurance like Medicaid, Medicare, or a "state-specific health plan" |
|
|
4=Active or retired military or dependent plan like the V.A. or |
|
|
5=Bureau of Indian Affairs/IHS/Urban Indian Health |
|
|
7=Other |
|
|
8=Don‘t know / Not sure |
|
|
9=Refused |
|
|
|
287 |
P3_PTX_OthInsSpecify |
Other type of insurance (text) |
|
|
|
288 |
P3_PTX_PriCareDoc |
Do you have one person you think of as your personal doctor or health care provider? |
|
|
This data element should not be ‘null’ or contain missing values for interviewed cases. May be ‘Null’ (P3_IDX_Dispo) = ‘1’, partial interview. |
|
|
|
|
|
1=Yes, only one |
|
|
2=More than one or facility |
|
|
3=No |
|
|
4=Don't Know /Not Sure |
|
|
5=Refused |
|
|
|
289 |
P3_PTX_Hccost |
Was there a time in the past 12 months when you needed to see a doctor but could not because of cost? |
|
|
This data element should not be ‘null’ or contain missing values for interviewed cases. May be ‘Null’ (P3_IDX_Dispo) = ‘1’, partial interview. |
|
|
|
|
|
1=Yes |
|
|
2=No |
|
|
3=Don't Know /Don't Remember/ Not Sure |
|
|
4=Refused |
|
|
|
290 |
P3_PTX_OOPE |
When you went to see _______________ (mention provider, clinic or facility name) when you were diagnosed with gonorrhea, did you need to pay anything out-of-pocket at the time of your visit? |
|
|
This data element should not be ‘null’ or contain missing values for interviewed cases. May be ‘Null’ (P3_IDX_Dispo) = ‘1’, partial interview. |
|
|
|
|
|
1=Yes |
|
|
2=No |
|
|
3=Don't Know /Don't Remember/ Not Sure |
|
|
4=Refused |
|
|
|
291 |
P3_PTX_SYMP1 |
Before you went to see _______________ (mention provider, clinic or facility name) when you were diagnosed with gonorrhea, did you have any unusual discharge or oozing from your (penis/vagina)? |
|
|
This data element should not be ‘null’ or contain missing values for interviewed cases. May be ‘Null’ (P3_IDX_Dispo) = ‘1’, partial interview. |
|
|
|
|
|
1=Yes |
|
|
2=No |
|
|
3=Don't Know /Don't Remember/ Not Sure |
|
|
4=Refused |
|
|
|
292 |
P3_PTX_SYMP2 |
Before you went to see _______________ (mention provider, clinic or facility name) did you notice any unexplained sores or bumps on your (penis/vagina)? |
|
|
This data element should not be ‘null’ or contain missing values for interviewed cases. May be ‘Null’ (P3_IDX_Dispo) = ‘1’, partial interview. |
|
|
|
|
|
1=Yes |
|
|
2=No |
|
|
3=Don't Know /Don't Remember/ Not Sure |
|
|
4=Refused |
|
|
|
293 |
P3_PTX_SYMP3 |
Before you went to see _______________ (mention provider, clinic or facility name) when you were diagnosed with gonorrhea, did you have any pain or burning when you urinated? |
|
|
This data element should not be ‘null’ or contain missing values for interviewed cases. May be ‘Null’ (P3_IDX_Dispo) = ‘1’, partial interview. |
|
|
|
|
|
1=Yes |
|
|
2=No |
|
|
3=Don't Know /Don't Remember/ Not Sure |
|
|
4=Refused |
|
|
|
294 |
P3_PTX_SYMP4 |
Did you go to the doctor that time because you were having symptoms or pains you thought might be from an STD |
|
|
This data element should not be ‘null’ or contain missing values for interviewed cases. May be ‘Null’ (P3_IDX_Dispo) = ‘1’, partial interview. |
|
|
|
|
|
1=Yes |
|
|
2=No |
|
|
3=Don't Know /Don't Remember/ Not Sure |
|
|
4=Refused |
|
|
|
|
|
|
295 |
P3_PTX_Delay |
How long did you have these symptoms or pains before you were able to see the doctor? |
|
|
This data element should not be ‘null’ or contain missing values for interviewed cases. May be ‘Null’ (P3_IDX_Dispo) = ‘1’, partial interview. |
|
|
|
|
|
1=1 Day |
|
|
2=2 - 6 Days |
|
|
3=1 - 2 weeks |
|
|
4=More than 2 weeks |
|
|
5=Don‘t know / Not sure / Don’t remember |
|
|
6=Refused |
|
|
|
296 |
P3_PTX_ExpSTD |
Before you went to the doctor that time, did any of your sex partners tell you that you might have been exposed to an STD? |
|
|
This data element should not be ‘null’ or contain missing values for interviewed cases. May be ‘Null’ (P3_IDX_Dispo) = ‘1’, partial interview. |
|
|
|
|
|
1=Yes |
|
|
2=No |
|
|
3=Don't Know /Don't Remember/ Not Sure |
|
|
4=Refused |
|
|
|
|
|
|
309 |
P3_PTX_PartnerTest |
Did the doctor, nurse or anyone else during that visit talk to you about the importance of getting your sex partners examined and tested for STDs? |
|
|
This data element should not be ‘null’ or contain missing values for interviewed cases. May be ‘Null’ (P3_IDX_Dispo) = ‘1’, partial interview. |
|
|
|
|
|
1=Yes |
|
|
2=No |
|
|
3=Don't Know /Don't Remember/ Not Sure |
|
|
4=Refused |
|
|
|
310 |
P3_PTX_TellParts |
In the time since your visit, did you tell any of your sex partners they may need to tested or treated for STDs? |
|
|
This data element should not be ‘null’ or contain missing values for interviewed cases. May be ‘Null’ (P3_IDX_Dispo) = ‘1’, partial interview. |
|
|
|
|
|
1=Yes |
|
|
2=No |
|
|
3=Don't Know /Don't Remember/ Not Sure |
|
|
4=Refused |
|
|
|
311 |
P3_PTX_EPToffer |
Did a doctor, nurse or someone at the health department offer to give you medications or a prescription for you to give to any of your sex partner(s)? |
|
|
This data element should not be ‘null’ or contain missing values for interviewed cases. May be ‘Null’ (P3_IDX_Dispo) = ‘1’, partial interview. |
|
|
|
|
|
1=Yes |
|
|
2=No |
|
|
3=Don't Know /Don't Remember/ Not Sure |
|
|
4=Refused |
|
|
|
312 |
P3_PTX_EPTWHO |
Who was it that offered you the additional medications or prescriptions? Was it someone from your doctor’s office or someone from the health department? |
|
|
This data element should not be ‘null’ or contain missing values for interviewed cases. May be ‘Null’ (P3_IDX_Dispo) = ‘1’, partial interview. |
|
|
|
|
|
1=My doctor’s office |
|
|
2=The health department |
|
|
3=Someone else |
|
|
4=Don‘t know / Not sure |
|
|
5=Refused |
|
|
|
313 |
P3_PTX_EPTGET |
Did you actually get the additional medications or prescriptions for your sex partners? |
|
|
This data element should not be ‘null’ or contain missing values for interviewed cases. May be ‘Null’ (P3_IDX_Dispo) = ‘1’, partial interview. |
|
|
|
|
|
1=Yes |
|
|
2=No |
|
|
3=Don't Know /Don't Remember/ Not Sure |
|
|
4=Refused |
|
|
|
314 |
P3_PTX_EPTMEDORRX |
Did you get medicine to give to your partner? Or did you get prescriptions that your partners needed to have filled at a pharmacy? |
|
|
This data element should not be ‘null’ or contain missing values for interviewed cases. May be ‘Null’ (P3_IDX_Dispo) = ‘1’, partial interview. |
|
|
|
|
|
1=I got additional medications |
|
|
2=I got prescription(s) |
|
|
3=Don‘t know / Not sure |
|
|
|
315 |
P3_PTX_EPTGAVE |
Did you give the additional medications or prescriptions to at least one of your sex partners? |
|
|
This data element should not be ‘null’ or contain missing values for interviewed cases. May be ‘Null’ (P3_IDX_Dispo) = ‘1’, partial interview. |
|
|
|
|
|
1=Yes |
|
|
2=No |
|
|
9=Refused |
|
|
|
316 |
P3_PTX_EPTPARTTAKE |
Do you think at least one of your sex partners took this medication? |
|
|
|
|
|
1=Yes, I think at least one of my partner(s) took this medicine |
|
|
2=No, I do not think any of my partner(s) took these medicines |
|
|
9=Refused |
|
|
|
|
|
|
317 |
P3_PTX_HIVtested |
Did you get tested for HIV at that visit? |
|
|
This data element should not be ‘null’ or contain missing values for interviewed cases. May be ‘Null’ (P3_IDX_Dispo) = ‘1’, partial interview. |
|
|
|
|
|
1=Yes |
|
|
2=No |
|
|
3=Don't Know /Don't Remember/ Not Sure |
|
|
4=Refused |
|
|
|
318 |
P3_PTX_HIVresult |
What was the result of your HIV test at that visit? |
|
|
This data element should not be ‘null’ or contain missing values if P3_PTX_HIVtested=1. |
|
|
|
|
|
1=Positive |
|
|
2=Negative |
|
|
3=Don't Know / Not Sure / did not get results |
|
|
4=Refused |
|
|
|
319 |
P3_PTX_everHIVtst |
Have you ever been tested for HIV? |
|
|
May be ‘Null’ if P3_PTX_HIVtested=1. This data element should not be ‘null’ or contain missing values for cases responding with 2, 3 or 4 to P3_PTX_HIVtested. |
|
|
|
|
|
1=Yes |
|
|
2=No |
|
|
3=Don't Know /Don't Remember/ Not Sure |
|
|
4=Refused |
|
|
|
320 |
P3_PTX_whenHIVtest |
When was your last HIV test? Just month and year is ok? (IF PATIENT UNABLE TO RECALL, PROBE UNTIL APPROXIMATE RESPONSE ELICITED) |
|
|
This should be character data ”MM/YYYY”, missing/REFUSED information as”../YYYY” or “../….” |
|
|
|
321 |
P3_PTX_HIVeverResult |
What was the result of that HIV test? |
|
|
This data element should not be ‘null’ or contain missing values for cases responding to P3_PTX_everHIVtst=1. |
|
|
|
|
|
1=Positive |
|
|
2=Negative |
|
|
3=Don't Know / Not Sure / did not get results |
|
|
4=Refused |
|
|
|
322 |
P3_PTX_inHIVcare |
When was your most recent visit to a doctor, nurse or other health |
|
|
This data element should not be ‘null’ or contain missing values for cases identifying as HIV positive (P3_PTX_HIVResult=1 or P3_PTX_HIVeverResult=1). This should be entered as character data ”MM/YYYY”, missing/REFUSED information as”../YYYY” or “../….” |
|
|
|
323 |
P3_PTX_ART |
Are you taking antiretroviral medicines to treat your HIV infection? |
|
|
This data element should not be ‘null’ or contain missing values for cases identifying as HIV positive (P3_PTX_HIVResult=1 or P3_PTX_HIVeverResult=1). This should be entered as character data ”MM/YYYY”, missing/REFUSED information as”../YYYY” or “../….” |
|
|
|
|
|
1=Yes |
|
|
2=No |
|
|
3=Don't Know /Don't Remember/ Not Sure |
|
|
4=Refused |
|
|
|
324 |
P3_PTX_PrEP |
When you were diagnosed with gonorrhea, did your health care provider or anyone else discuss medications to help you prevent getting HIV? |
|
|
This data element should be ‘null’ for patients reporting being HIV positive. This data element should not be ‘null’ or contain missing values for patients identifying as HIV negative or unknown HIV status. |
|
|
0=No, I am already on PrEP |
|
|
1=Yes |
|
|
2=No |
|
|
3= Don‘t know / Not sure |
|
|
4=Refused |
|
|
|
325 |
P3_PTX_PREP1 |
Did your health care provider offer to prescribe or give you |
|
|
medications to help you prevent getting HIV? |
|
|
This data element should not be ‘null’ or contain missing values if patient reports PrEP. |
|
|
|
|
|
1=Yes |
|
|
2=No |
|
|
3=Don't Know /Don't Remember/ Not Sure |
|
|
4=Refused |
|
|
|
326 |
P3_PTX_PREP2 |
Did you fill a prescription or get medications to help you prevent getting HIV? |
|
|
|
|
|
This data element should not be ‘null’ or contain missing values for those answering “Yes” to P3_PTX_PrEP. |
|
|
|
|
|
1=Yes |
|
|
2=No |
|
|
3=Don't Know /Don't Remember/ Not Sure |
|
|
4=Refused |
|
|
|
327 |
P3_PTX_PREP3 |
Are you currently taking daily medications to help you prevent |
|
|
getting HIV (on PrEP)? This is often called PrEP, or pre-exposure prophylaxis. |
|
|
This data element should not be ‘null’ or contain missing values. |
|
|
|
|
|
1=Yes |
|
|
2=No |
|
|
3=Don't Know /Don't Remember/ Not Sure |
|
|
4=Refused |
327.1 |
P3_mpox |
Has a doctor or other health care provider ever told you that you had Mpox (monkeypox)?
1=Yes 2=No 3= Don't Know/Not sure/Unknown 4=Refused
|
327.2 |
P3_mpox_vax |
Have you ever received a vaccine for mpox? |
|
|
|
|
|
1=Yes |
|
|
2=No (skip to 328) |
|
|
3=Don't Know/Not sure/Unknown (skip to 328) |
|
|
4=Refused (skip to 328) |
|
|
|
327.3 |
P3_mpox_vaxD |
How many doses of vaccine for mpox have you received? |
|
|
|
|
|
1=One |
|
|
2=Two |
|
|
3=Don't Know/Not sure/Unknown |
|
|
4=Refused |
|
|
|
327.4 |
P3_mpox_vaxDTE |
When was your last mpox vaccine shot? |
|
|
|
|
|
This should be character data: ”MM/YYYY”, |
|
|
missing/REFUSED information as”../YYYY” or “../….” |
|
|
|
328 |
P3_PTX_Pregnant |
Were you pregnant at the time you were told that you had gonorrhea? |
|
|
This data element should not be ‘null’ or contain missing value for female cases interviewed. May be null for partial interviews, must be null for male cases. |
|
|
|
|
|
1=Yes |
|
|
2=No |
|
|
3=Don't Know /Don't Remember/ Not Sure |
|
|
4=Refused |
|
|
|
329 |
P3_PTX_GenderSP |
During the past 12 months, have you had sex with only males, only females or both? |
|
|
This data element should not be ‘null’ or contain missing values for interviewed cases. May be ‘Null’ if P3_IDX_Dispo) = ‘1’, partial interview. |
|
|
|
|
|
1=Males only |
|
|
2=Females only |
|
|
3=Both Males and Females |
|
|
4=Unknown |
|
|
9=refused |
|
|
|
330 |
P3_PTX_TGSP |
During the past 12 months, have you had sex with a transgender man or transgender woman? |
|
|
|
|
|
1=Yes |
|
|
2=No |
|
|
3=Don't Know /Don't Remember/ Not Sure |
|
|
4=Refused |
|
|
|
331 |
P3_PTX_Sxorient |
Do you consider yourself to be… |
|
|
This data element should not be ‘null’ or contain missing values for interviewed cases. May be ‘Null’ if P3_IDX_Dispo) = ‘1’, partial interview. |
|
|
|
|
|
1=Heterosexual/Straight (not Gay or Lesbian) |
|
|
2=Gay/Lesbian/Homosexual |
|
|
3=Bisexual |
|
|
4=Other/Don't Know |
|
|
9=Refused |
|
|
|
332 |
P3_PTX_MaleSPL3MO |
Thinking back to the 3 months before you were diagnosed with |
|
|
This data element should not be ‘null’ or contain missing values for interviewed cases. May be ‘Null’ if P3_IDX_Dispo = ‘1’, partial interview. Probe for approximate response or ‘best’ guess. Enter 0 to indicate ‘None’, 9999 to indicate “Refused”. |
|
|
|
333 |
P3_PTX_FemaleSPL3MO |
Thinking back to the 3 months before you were diagnosed with |
|
|
This data element should not be ‘null’ or contain missing values for interviewed cases. May be ‘Null’ if P3_IDX_Dispo = ‘1’, partial interview. May be ‘Null’ if P3_IDX_Dispo = ‘1’, partial interview. Probe for approximate response or ‘best’ guess. Enter 0 to indicate ‘None’, 9999 to indicate “Refused”. |
|
|
|
334 |
P3_PTX_SPtreatOne |
To the best of your knowledge, was your sex partner treated? |
|
|
This data element is for patient reporting only a single sex partner. |
|
|
|
|
|
1=Yes, definitely |
|
|
2=Yes, probably |
|
|
3=Don't Know / Not Sure |
|
|
4=No, probably not |
|
|
5=Refused |
|
|
6=No need/no partners infected |
|
|
|
335 |
P3_PTX_SPtreatMult |
To the best of your knowledge, would you say that all of your sex partners were definitely treated, at least one of your partners was definitely treated, or that none were treated? |
|
|
This data element is for patients reporting multiple sex partners. |
|
|
|
|
|
1=All definitely treated |
|
|
2=At least one definitely treated |
|
|
3=At least one probably treated |
|
|
4=Not sure |
|
|
5=Probably none treated |
|
|
6=Refused |
|
|
7=No need/no partners infected |
|
|
|
336 |
P3_PTX_SexExch |
During the past 12 months, have you given drugs or money in exchange for sex or received drugs or money in exchange for sex? By sex we mean vaginal, oral, or anal sex. |
|
|
This data element should not be ‘null’ or contain missing values for interviewed cases. May be ‘Null’ if P3_IDX_Dispo = ‘1’, partial interview. |
|
|
|
|
|
1=Yes |
|
|
2=No |
|
|
3=Don't Know /Don't Remember/ Not Sure |
|
|
4=Refused |
|
|
|
337 |
P3_PTX_Opioid |
In the past year, how often have you used prescription pain medications |
|
|
other than as prescribed by a doctor? |
|
|
This data element should not be ‘null’ or contain missing values for interviewed cases. May be ‘Null’ if #107 (P3_IDX_Dispo) = ‘1’, partial interview. |
|
|
|
|
|
1=Never |
|
|
2=Once or Twice |
|
|
3=Monthly |
|
|
4=Weekly |
|
|
5=Daily or Almost Daily |
|
|
9=Refused |
|
|
|
338 |
P3_IVDU |
In the past year, have you used any injection drugs such as heroin, cocaine or meth? |
|
|
|
|
|
1=Yes |
|
|
2=No |
|
|
3=Don’t Know/Can’t Remember |
|
|
4=Refused |
|
|
|
339 |
P3_IVDU_HER |
In the past year, did you inject heroin? |
|
|
|
|
|
1=Yes |
|
|
2=No |
|
|
3=Don’t Know/Can’t Remember |
|
|
4=Refused |
|
|
|
339.1 |
P3_IVDU_COC |
In the past year, did you inject cocaine/crack? |
|
|
|
|
|
1=Yes |
|
|
2=No |
|
|
3=Don’t Know/Can’t Remember |
|
|
4=Refused |
|
|
|
339.2 |
P3_IVDU_MTH |
In the past year, did you inject Crystal Meth/Methamphetamine/Methadrone? |
|
|
|
|
|
1=Yes |
|
|
2=No |
|
|
3=Don’t Know/Can’t Remember |
|
|
4=Refused |
|
|
|
339.3 |
P3_IVDU_OXY |
In the past year, did you inject Oxycodone/morphine/Fentanyl/Carfentanil/some other opioid? |
|
|
|
|
|
1=Yes |
|
|
2=No |
|
|
3=Don’t Know/Can’t Remember |
|
|
4=Refused |
|
|
|
339.4 |
P3_IVDU_OTH |
In the past year, did you inject other durgs not listed? |
|
|
|
|
|
1=Yes |
|
|
2=No |
|
|
3=Don’t Know/Can’t Remember |
|
|
4=Refused |
|
|
|
340 |
P3_IVDU_DR_TX |
Other drug injected text. |
|
|
|
|
|
|
341 |
P3_PTX_LastSex |
When was the last time you had sex? |
|
|
This data element should not be ‘null’ or contain missing values for interviewed cases. May be ‘Null’ if P3_IDX_Dispo = ‘1’, partial interview. |
|
|
|
|
|
1=In last week |
|
|
2=> 1 week but within last month |
|
|
3=> 1 month, but within 2 months |
|
|
4=> 2 months ago |
|
|
5=Don't Know / Not sure |
|
|
9=Refused |
|
|
|
342 |
P3_PTX_GenderMRSP |
Thinking back to the last time you had sex, was the person you had sex with…? |
|
|
This data element should not be ‘null’ or contain missing values for interviewed cases. May be ‘Null’ if P3_IDX_Dispo = ‘1’, partial interview. |
|
|
|
|
|
1=Male (not transgender) |
|
|
2=Female (not transgender) |
|
|
3=Male-to-Female TG |
|
|
4=Female-to-Male TG |
|
|
5=TG But Unknown or Unspecified |
|
|
6=Queer, Gender Non-binary |
|
|
7=Other |
|
|
9=Refused or Not Captured |
|
|
|
343 |
P3_PTX_AgeMRSP |
Thinking back to the last person you had sex with, how old do you think that person is? If you don’t know for sure, it’s OK to make your best guess. |
|
|
This data element should not be ‘null’ or contain missing values for interviewed cases. May be ‘Null’ if P3_IDX_Dispo = ‘1’, partial interview. |
|
|
|
344 |
P3_PTX_HISPMRSP |
Would you say that person is Hispanic/Latino/a? If you don’t know for sure, it’s OK to make your best guess. |
|
|
This data element should not be ‘null’ or contain missing values for interviewed cases. May be ‘Null’ if P3_IDX_Dispo = ‘1’, partial interview. |
|
|
|
|
|
1=Yes, Hispanic |
|
|
2=No, Not Hispanic |
|
|
8=Unknown/Can't guess |
|
|
9=Refused |
|
|
|
345 |
P3_PTX_RaceMRSP |
Thinking back to the last person you had sex with, what race(s) would you say that person is? If you don’t know for sure, it’s OK to make your best guess. |
|
|
This data element should not be ‘null’ or contain missing values for interviewed cases. May be ‘Null’ if P3_IDX_Dispo = ‘1’, partial interview. |
|
|
|
|
|
1=White |
|
|
2=Black |
|
|
3=AI/AN |
|
|
4=ASIAN |
|
|
5=NH/OPI |
|
|
6=Multiple Races |
|
|
7=Unknown/Can't guess |
|
|
9=Refused |
|
|
|
346 |
P3_PTX_MRSPHIV |
Thinking back to the last person you had sex with, do you know if that person HIV positive? |
|
|
This data element should not be ‘null’ or contain missing values for interviewed cases. May be ‘Null’ if P3_IDX_Dispo = ‘1’, partial interview. |
|
|
|
|
|
1=Yes, I know that person is HIV positive |
|
|
2=No, I know that person is HIV negative |
|
|
3=Don't Know /Don't Remember/ Not Sure |
|
|
4=Refused |
|
|
|
347 |
P3_PTX_SexAgainMRSP |
Thinking back to the last person you had sex with; do you think you will have sex with this person again? |
|
|
This data element should not be ‘null’ or contain missing values for interviewed cases. May be ‘Null’ if P3_IDX_Dispo = ‘1’, partial interview. |
|
|
|
|
|
1=Yes |
|
|
2=No |
|
|
3=Don't Know /Maybe/ Not Sure |
|
|
4=Refused |
|
|
|
|
|
|
|
|
|
|
Data Element Name |
Description/Response Coding |
|
Laboratory Observation Dataset - sourced from laboratory reporting or case investigations |
|
|
|
|
351 |
P1_L1_EventID |
Unique identifier for associated surveillance record |
|
|
Will be a primary key for merging lab and case data; should correspond to P1_EventID. This data element MUST NOT be ‘null’ or contain missing values. |
|
|
|
352 |
P1_L1_LabID |
Unique identifier for laboratory performing testing |
|
|
Site assigned; may be ID from other system or specifically created for SSuN. If performing lab is not known, site should still create a lab record with a locally defined ID corresponding to unknown lab that they will use throughout the SSuN data collection period. This data element should not be ‘null’ or contain missing values. |
|
|
|
353 |
P1_L1_Accession |
Unique identifier (accession number) for laboratory record |
|
|
Leave blank (null) if not available/ascertained |
|
|
|
353.1 |
P1_L1_Source |
Did this lab record originate from eHARS Match? |
|
|
Default code to '0' for lab record NOT from eHARS |
|
|
|
354 |
P1_L1_PatientID |
Unique identifier for person (allowing longitudinal tracking of persons) |
|
|
Will be a secondary key for merging lab and case data; should correspond to P1_PatientID. This data element MUST NOT be ‘null’ or contain missing values. |
|
|
|
355 |
P1_L1_CondTested |
specific condition/pathogen tested |
|
|
This data element MUST NOT be ‘null’ or contain missing values. |
|
|
|
|
|
1=Syphilis |
|
|
2=Gonorrhea |
|
|
3=Chlamydia |
|
|
4=Genital Herpes |
|
|
5=Trichomoniasis |
|
|
6=HIV |
|
|
7=Hep A |
|
|
8=Hep B |
|
|
9=Hep C |
|
|
10=BV |
|
|
11=Other |
|
|
|
356 |
P1_L1_SpecColDte |
Specimen collection date - this is often used as a proxy for diagnosis |
|
|
This data element should not be ‘null’ or contain missing values. This should be coded as a ‘SAS’ numeric date. |
|
|
|
357 |
P1_L1_LabRepDte |
This is the date that the performing lab reported the results to the |
|
|
This should be coded as a ‘SAS’ numeric date. |
|
|
|
358 |
P1_L1_SpecType |
Type of specimen |
|
|
This data element should not be ‘null’ or contain missing values. |
|
|
|
|
|
1=Exudate |
|
|
2=Blood/sera |
|
|
3=Synovial fluid |
|
|
4=Urine |
|
|
5=CSF |
|
|
6=Tissue |
|
|
7=Saliva |
|
|
8=Other |
|
|
9=Unknown |
|
|
|
359 |
P1_L1_AnatSite |
This is the anatomic site from which the specimen was obtained and is important in determining the anatomic site of infection. |
|
|
This data element should not be ‘null’ or contain missing values. |
|
|
|
|
|
1=Urethra |
|
|
2=Vagina/cervix |
|
|
3=Urine |
|
|
4=Rectum |
|
|
5=Pharynx |
|
|
6=Eye |
|
|
7=Sera/Blood |
|
|
8=Joint |
|
|
9=Other Anatomic Site |
|
|
10=Unknown Anatomic Site |
|
|
|
360 |
P1_L1_TestType |
As test technology advances, it is important to obtain the type of test performed |
|
|
This data element should not be ‘null’ or contain missing values. |
|
|
|
|
|
1=Culture |
|
|
2=NAAT |
|
|
3=Non-amplified nucleic acid test/DNA probe |
|
|
4=Gram Stain |
|
|
5=DFA |
|
|
6=Rapid HIV |
|
|
7=ELISA |
|
|
8=Western blot (deprecated code, see 27, 28 below) |
|
|
9=Pooled RNA |
|
|
10=RPR |
|
|
11=VDRL |
|
|
12=FTA |
|
|
13=TP-PA |
|
|
14=MHA |
|
|
15=Wet Mount/Clue Cell |
|
|
16=PH |
|
|
17=Other, not listed |
|
|
18=Unknown |
|
|
22=HIV-1 IA (EIA or Other) |
|
|
23=HIV-1/2 IA (EIA or Other) |
|
|
24=HIV-2 IA (EIA or Other) |
|
|
25=HIV-1/2 Ag/Ab |
|
|
26=HIV-1/2 Type-Differentiating Immunoassay |
|
|
27=HIV-1 Western Blot |
|
|
28=HIV-2 Western Blot |
|
|
29=HIV-1 IFA |
|
|
30=HIV-1 Culture |
|
|
31=HIV-2 Culture |
|
|
32=HIV-1 p24 Antigen |
|
|
33=HIV-1 RNA/DNA NAAT (Qualitative) |
|
|
34=HIV-2 RNA/DNA NAAT (Qualitative) |
|
|
35=HIV-1 RNA/DNA NAAT (Quantitative viral load) |
|
|
36=HIV-2 RNA/DNA NAAT (Quantitative viral load) |
|
|
37=CD4 T-lymphocytes |
|
|
38=CD4 Percent |
|
|
39=HIV-1 Genotype (PR Nucleotide Sequence) |
|
|
40=HIV-1 Genotype (RT Nucleotide Sequence) |
|
|
41=HIV-1 Genotype (PR/RT Nucleotide Sequence) |
|
|
42=HIV-1 Genotype (IN Nucleotide Sequence) |
|
|
43=HIV-1 Genotype (PR/RT/IN Nucleotide Sequence) |
|
|
44=STARHS (BED) |
|
|
45=STARHS (Vironostika-LS) |
|
|
46=STARHS ( BIO-RAD AVIDITY) |
|
|
47=STARHS (Other) |
|
|
48=STARHS (Unknown) |
|
|
49=Rapid (Retired) |
|
|
50=HIV-1/2 Ag/Ab-Distinguishing Immunoassay |
|
|
51=HIV-1 Genotype (EN Nucleotide Sequence) |
|
|
52=HIV-1 Genotype (FI Nucleotide Sequence) |
|
|
53=HIV-1/2 Ag/Ab and Type-Differentiating Immunoassay |
|
|
54=HIV-1/2 Ag/Ab and Type-Differentiating IA - HIV-1 p24 Antigen Analyte |
|
|
55=HIV-1/2 Ag/Ab and Type-Differentiating IA - HIV-1 Antibody Analyte |
|
|
56=HIV-1/2 Ag/Ab and Type-Differentiating IA - HIV-2 Antibody Analyte |
|
|
57=HIV-1/2 Type-Differentiating Immunoassay (Supplemental) |
|
|
58=HIV-1/2 Type-Differentiating IA (Suppl) - HIV-1 Antibody Analyte |
|
|
59=HIV-1/2 Type-Differentiating IA (Suppl) - HIV-2 Antibody Analyte |
|
|
60=HIV-1 Genotype (Unspecified) |
|
|
61=WB/IFA-Legacy |
|
|
62=RIPA-Legacy |
|
|
63=Latex Ag-Legacy |
|
|
64=Peptide-Legacy |
|
|
65=Rapid-Legacy |
|
|
66=Iga-Legacy |
|
|
67=IVAP-Legacy |
|
|
68=Other HIV Antibody-Other-Legacy |
|
|
69=Other HIV Antibody-Unspecified-Legacy |
|
|
70=Viral Load-Other-Legacy |
|
|
71=Viral Load-Unspecified-Legacy |
|
|
72=HIV Detection/Antigen/Viral Load-Other-Legacy |
|
|
73=HIV Detection/Antigen/Viral Load-Unspecified-Legacy |
|
|
80=Pregnancy |
|
|
88= Other |
|
|
99=Not captured |
|
|
|
361 |
P1_L1_QualRes |
Qualitative result: For most pathogens/tests, positive, negative, |
|
|
This data element should not be ‘null’ or contain missing values. |
|
|
|
|
|
1=Positive |
|
|
2=Negative |
|
|
3=Reactive |
|
|
4=Weakly Reactive |
|
|
5=Non-Reactive |
|
|
6=Equivocal/Indeterminate |
|
|
7=Specimen Inadequate/Contaminated |
|
|
8=Other |
|
|
9=Unknown |
|
|
|
362 |
P1_L1_Quantres |
Numeric - or Ratio (for RPR/VDRL, e.g. 1:2, 1:4, etc.) |
|
|
|
363 |
P1_L1_QuantUnits |
Units for quantitative results: |
|
|
1=Copies/mL |
|
|
2=Log Copies/mL |
|
|
3=Cells/Cubic mm |
|
|
4=CD4% |
|
|
5=Titer Ratio |
|
|
6=Cycles/Time (rtPCR) |
|
|
|
|
Data Element Name |
Description/Response Coding |
|
Provider Reference Dataset (information should be updated annually) |
|
|
|
|
364 |
P4_ProvID |
Unique identifier for provider/facility |
|
|
This data element MUST NOT be ‘null’ or contain missing values. |
|
|
|
365 |
P4_ProvName |
Name of provider or facility |
|
|
|
366 |
P4_ProvCO |
FIPS code for provider/facility physical location |
|
|
|
367 |
P4_ProvZIP |
Facility/provider physical location 5-digit ZIP |
|
|
This data element should not be ‘null’ or contain missing values. |
|
|
|
368 |
P4_UpdateDate |
Date provider information last updated/verified |
|
|
This data element should not be ‘null’ or contain missing values. This |
|
|
|
369 |
P4_LocationLon |
Provider physical location longitude |
|
|
|
370 |
P4_LocationLat |
Provider physical location latitude |
|
|
|
371 |
P4_CensusTract |
Census tract of provider physical location |
|
|
|
372 |
P4_Prov_Fac_Type |
Facility or provider type code (PHINVAD compatible) |
|
|
This data element MUST NOT be ‘null’ or contain missing values. |
|
|
|
|
|
1=Blood Bank |
|
|
Includes for-profit sera collection centers |
|
|
2=Correctional Facilities |
|
|
Includes jails, prisons, juvenile detention, etc. |
|
|
3=Day care center (environment) |
|
|
4=Dentist |
|
|
5=Drug Treatment Facility |
|
|
6=Emergency Room/Emergency Department |
|
|
Include HMO/other urgent care in this category |
|
|
7=Family Planning Facility |
|
|
Includes reproductive health clinics |
|
|
8=Other Federal Agencies |
|
|
Do not include bureau of prisons in this category (should be 2, |
|
|
9=HIV Care Facility |
|
|
Includes and care facility whose primary service is HIV care |
|
|
10=HIV Counseling and Testing Site |
|
|
Include HIV outreach & street testing in this category |
|
|
11=Hospital - Not ED/ER |
|
|
This should include in-patient facilities where the patient was |
|
|
12=Labor and Delivery |
|
|
13=Laboratory |
|
|
14=Managed Care/HMOs |
|
|
15=Mental Health Provider |
|
|
16=Military |
|
|
17=National Job Training Program |
|
|
18=Other, not otherwise specified |
|
|
19=Other Health Department Clinic |
|
|
Do not include health department clinics whose primary |
|
|
20=Other State and Local Agencies |
|
|
21=Other Treatment Center |
|
|
22=Pharmacy |
|
|
23=Prenatal/Obstetrics Facility |
|
|
24=Private physicians' group office |
|
|
25=Public Health Clinic |
|
|
Include ONLY public clinics not otherwise categorized |
|
|
26=Data/Disease Registries |
|
|
27=Rural Health Clinic |
|
|
Includes clinics specifically designated as RHCs on the Centers |
|
|
28=Categorical STD Clinic |
|
|
29=School-Based Clinic |
|
|
30=TB Clinic |
|
|
31=Tribal Government Clinic |
|
|
Do not include IHS hospitals (those are coded as 32) |
|
|
32=Indian Health Service |
|
|
33=Veterinary Sources |
|
|
34=Vital Statistics |
|
|
99=unknown |
|
|
|
373 |
P4_ProvCHC |
Is facility/provider a Community Health Center (CHC)? |
|
|
This data element should not be ‘null’ or contain missing values. |
|
|
|
|
|
1=Yes |
|
|
2=No |
|
|
3=Unknown/Missing |
|
|
|
374 |
P4_ProvFQHC |
Is facility/provider a Federally Qualified Health Center (FQHC)? |
|
|
This data element should not be ‘null’ or contain missing values. |
|
|
|
|
|
1=Yes |
|
|
2=No |
|
|
3=Unknown/Missing |
|
|
|
375 |
P5_S1SiteID |
Site ID |
|
|
This 2 character code primarily identifies sites funded under SSuN Cycle 2 & 3 and will include additional sites as required for Cycle 4. This data element MUST NOT be ‘null’ or contain missing values. |
|
|
BA=Baltimore (Cycle II, Cycle III, Cycle IV) |
|
|
CB=Columbus (Cycle IV) |
|
|
CA=California (Cycle II, Cycle III, Cycle IV) |
|
|
FL=Florida (Cycle III & Cycle IV) |
|
|
IN=Indiana (Cycle IV) |
|
|
MC=Multnomah County (Cycle III &Cycle IV) |
|
|
NY=New York City (Cycle II, Cycle III, Cycle IV) |
|
|
PH=Philadelphia (Cycle II, Cycle III, Cycle IV) |
|
|
SF=San Francisco (Cycle II, Cycle III, Cycle IV) |
|
|
WA= Washington (Cycle II, Cycle III, Cycle IV) |
|
|
UT=UTAH (Cycle IV) |
|
|
LA=Louisana (Cycle II) |
|
|
VA=Virginia (Cycle II) |
|
|
AL=Alabama (Cycle II) |
|
|
CO=Colorado (Cycle II) |
|
|
CH=Chicago (Cycle II) |
|
|
MA=Massachusetts (Cycle III) |
|
|
MN=Minnesota (Cycle III) |
|
|
|
376 |
P5_S1EventID |
Site generated unique event identifier |
|
|
This record ID should be supplied by the site and may be an event or report identifier from underlying surveillance system. Regardless of source, this ID must be unique for each confirmed case report. This data element MUST NOT be ‘null’ or contain missing values. This must match the syphilis record in the Strategy B case file. |
|
|
|
377 |
P5_S1PatientID |
Site generated ID allows for longitudinal tracking of unique persons |
|
|
This ID should be supplied by the site and may be a unique patient identifier from underlying surveillance systems or may be generated specifically for SSuN from identifying information provided through case reporting. Regardless of source, this ID must be unique and allow for longitudinal tracking of persons reported with multiple episodes of disease. This data element MUST NOT be ‘null’ or contain missing values. This must match the syphilis record in the Strategy B case file. |
|
|
|
378 |
P5_S1PREG_NETSS |
Pregnancy status for female syphilis cases |
|
|
1=Yes |
|
|
2=No |
|
|
9=Unknown |
|
|
|
379 |
P5_S1HIVSTAT_NETSS |
Documented or self-reported HIV status at the time of event. |
|
|
P = HIV positive |
|
|
N = HIV negative |
|
|
E = Equivocal HIV test |
|
|
U = Unknown |
|
|
R = Refused to answer |
|
|
D = Did not ask |
|
|
|
380 |
P5_S1MSex12_NETSS |
Had sex with a male within past 12 months? |
|
|
|
|
|
Y=Yes |
|
|
N=No |
|
|
R=Refused |
|
|
D=Did not ask |
|
|
|
381 |
P5_S1FSex12_NETSS |
Had sex with a female within past 12 months? |
|
|
|
|
|
Y=Yes |
|
|
N=No |
|
|
R=Refused |
|
|
D=Did not ask |
|
|
|
382 |
P5_S1AnSex12_NETSS |
Had sex with an anonymous partner within past 12 months? |
|
|
|
|
|
Y=Yes |
|
|
N=No |
|
|
R=Refused |
|
|
D=Did not ask |
|
|
|
383 |
P5_S1SxIDU12_NETSS |
Had sex with an IVDU within past 12 months? |
|
|
|
|
|
Y=Yes |
|
|
N=No |
|
|
R=Refused |
|
|
D=Did not ask |
384 |
P5_S1SxINTX12_NETSS |
Had sex wwhile intoxicated within past 12 months? |
|
|
|
|
|
Y=Yes |
|
|
N=No |
|
|
R=Refused |
|
|
D=Did not ask |
|
|
|
385 |
P5_S1SxEX12_NETSS |
Exchanged drugs/money for sex within past 12 months? |
|
|
|
|
|
Y=Yes |
|
|
N=No |
|
|
R=Refused |
|
|
D=Did not ask |
|
|
|
386 |
P5_S1SxFMSM12_NETSS |
Had sex with MSM in last 12 months (females only)? |
|
|
|
|
|
Y=Yes |
|
|
N=No |
|
|
R=Refused |
|
|
D=Did not ask |
|
|
|
387 |
P5_S1IVDU12_NETSS |
Engaged in injection drug use in last 12 months? |
|
|
|
|
|
Y=Yes |
|
|
N=No |
|
|
R=Refused |
|
|
D=Did not ask |
|
|
|
388 |
P5_S1Crack12_NETSS |
Used crack last 12 months? |
|
|
|
|
|
Y=Yes |
|
|
N=No |
|
|
R=Refused |
|
|
D=Did not ask |
|
|
|
389 |
P5_S1Coke12_NETSS |
Used cocaine last 12 months? |
|
|
|
|
|
Y=Yes |
|
|
N=No |
|
|
R=Refused |
|
|
D=Did not ask |
|
|
|
390 |
P5_S1Heroin12_NETSS |
Used heroin last 12 months? |
|
|
|
|
|
Y=Yes |
|
|
N=No |
|
|
R=Refused |
|
|
D=Did not ask |
|
|
|
391 |
P5_S1Meth12_NETSS |
Used methamphetamine last 12 months? |
|
|
|
|
|
Y=Yes |
|
|
N=No |
|
|
R=Refused |
|
|
D=Did not ask |
|
|
|
932 |
P5_S1Pops12_NETSS |
Used poppers/nitrates last 12 months? |
|
|
|
|
|
Y=Yes |
|
|
N=No |
|
|
R=Refused |
|
|
D=Did not ask |
|
|
|
393 |
P5_S1EDdru12_NETSS |
Used ED drugs last 12 months? |
|
|
|
|
|
Y=Yes |
|
|
N=No |
|
|
R=Refused |
|
|
D=Did not ask |
|
|
|
394 |
P5_S1OTHdru12_NETSS |
Used other drugs last 12 months? |
|
|
|
|
|
Y=Yes |
|
|
N=No |
|
|
R=Refused |
|
|
D=Did not ask |
|
|
|
395 |
P5_S1NOdru12_NETSS |
No drug use reported last 12 months? |
|
|
|
|
|
Y=Yes |
|
|
N=No |
|
|
R=Refused |
|
|
D=Did not ask |
|
|
|
396 |
P5_S1INCAR12_NETSS |
Incarcerated in last 12 months? |
|
|
|
|
|
Y=Yes |
|
|
N=No |
|
|
R=Refused |
|
|
D=Did not ask |
|
|
|
397 |
P5_S1STIever_NETSS |
Does the patient have a history of ever having had an STD prior to the condition reported in this case report? |
|
|
|
|
|
Y=Yes |
|
|
N=No |
|
|
U=Unknown |
|
|
R=Refused |
|
|
|
398 |
P5_S1SxInet12_NETSS |
Did the patient use an online computer site to exchange messages by typing them onscreen to engage in conversation with other visitors to the site for the purpose of having sex? |
|
|
|
|
|
Y=Yes |
|
|
N=No |
|
|
R=Refused |
|
|
D=Did not ask |
|
|
|
399 |
P5_S1TotSP12_NETSS |
Total number of sex partners last 12 months (###) |
|
|
|
|
|
888=Refused |
|
|
999=Unknown |
|
|
|
400 |
P5_S1LSNANUS_NETSS |
One or more lesion(s) indicative of syphilis were present in the anus or rectum. |
|
|
|
|
|
Y=Yes |
|
|
U=Default |
|
|
|
401 |
P5_S1LSNPENIS_NETSS |
One or more lesion(s) indicative of syphilis were present on the penis. |
|
|
|
|
|
Y=Yes |
|
|
U=Default |
|
|
|
402 |
P5_S1LSNSCRO_NETSS |
One or more lesion(s) indicative of syphilis were present on the scrotum. |
|
|
|
|
|
Y=Yes |
|
|
U=Default |
|
|
|
403 |
P5_S1LSNVAGI_NETSS |
One or more lesion(s) indicative of syphilis were present on the vagina. |
|
|
|
|
|
Y=Yes |
|
|
U=Default |
|
|
|
404 |
P5_S1LSNCERV_NETSS |
One or more lesion(s) indicative of syphilis were present on the cervix. |
|
|
|
|
|
Y=Yes |
|
|
U=Default |
|
|
|
405 |
P5_S1LSNPHAR_NETSS |
One or more lesion(s) indicative of syphilis were present in the nasopharynx. |
|
|
|
|
|
Y=Yes |
|
|
U=Default |
|
|
|
406 |
P5_S1LSNORAL_NETSS |
One or more lesion(s) indicative of syphilis were present in the mouth/oral cavity. |
|
|
|
|
|
Y=Yes |
|
|
U=Default |
|
|
|
407 |
P5_S1LSNEYE_NETSS |
One or more lesion(s) indicative of syphilis were present in the eye/conjunctiva. |
|
|
|
|
|
Y=Yes |
|
|
U=Default |
|
|
|
408 |
P5_S1LSNHEAD_NETSS |
One or more lesion(s) indicative of syphilis were present on the head. |
|
|
|
|
|
Y=Yes |
|
|
U=Default |
|
|
|
409 |
P5_S1LSNTORS_NETSS |
One or more lesion(s) indicative of syphilis were present on the torso. |
|
|
|
|
|
Y=Yes |
|
|
U=Default |
|
|
|
410 |
P5_S1NEURO_NETSS |
Does the patient have neurologic manifestations of syphilils? |
|
|
. = Missing |
|
|
1=Yes, Verified |
|
|
2=Yes, Likely |
|
|
3=Yes, Possible |
|
|
4=No |
|
|
9=Unknown |
|
|
|
411 |
P5_S1OCULAR_NETSS |
Does the patient have ocular manifestations of syphilils? |
|
|
. = Missing |
|
|
1=Yes, Verified |
|
|
2=Yes, Likely |
|
|
3=Yes, Possible |
|
|
4=No |
|
|
9=Unknown |
|
|
|
412 |
P5_S1OTIC_NETSS |
Does the patient have otic manifestations of syphilils? |
|
|
. = Missing |
|
|
1=Yes, Verified |
|
|
2=Yes, Likely |
|
|
3=Yes, Possible |
|
|
4=No |
|
|
9=Unknown |
|
|
|
413 |
P5_S1LATE_NETSS |
Does the patient have late clinical manifestations of syphilils? |
|
|
. = Missing |
|
|
1=Yes, Verified |
|
|
2=Yes, Likely |
|
|
4=No |
|
|
9=Unknown |
|
|
|
|
|
|
|
|
|
Form Approved |
|
|
OMB No. 0920-1072 |
|
|
Expiration Date: XX/XX/XXXX |
|
|
Attachment 5 – Data Elements List OMB Control#0920-1072
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Stenger, Mark R. (CDC/DDID/NCHHSTP/DSTDP) |
| File Modified | 0000-00-00 |
| File Created | 2023-08-02 |