Form I14 Mycoplasma Gentalium (MG)

Form Approved

OMB Control No.: 0920-1310

Expiration date: XX/XX/XXXX

Annual Evaluation and Performance Measurement Report (I.14- MYCOPLASMA GENTALIUM (MG))

Annually, each funded laboratory is required to report to CDC evaluation and performance measures. Data are used to indicate progress made toward program outcomes. These summary reports have to be uploaded to the ELC CAMP at the end of each funding year. Required performance measures are listed below.

	Urogenital/Urine		Rectal
	Male	Female	Male	Female
Number of specimens submitted by participating sites for MG identification via NAAT	#	#	#	#
Number of submitted specimens positive for MG	#	#	#	#
Number of MG-positive specimens tested for macrolide resistance associated mutations	#	#	#	#
Number of MG-positive specimens positive for macrolide resistance associated mutations	#	#	#	#
Number of MG-positive specimens tested for fluroquinolone resistance associated mutations	#	#	#	#
Number of MG-positive specimens positive for fluroquinolone resistance associated mutations	#	#	#	#
% of results reported within required timeframe	%	%	%	%

Public reporting burden of this collection of information is estimated to average 20 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.  An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB Control Number.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NE, MS H21-8, Atlanta, Georgia 30333; ATTN: PRA 0920-1310