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Form Approved |
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OMB No. 0920-1282 |
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Expiration Date: 1/31/2023 |
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STD PCHD Performance Measurement |
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Year 1 |
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| Project Area: |
[Select Project Area] |
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| Period of Performance: |
1/1/2019 - 12/31/2019 |
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| Submission Date: |
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| If other reporting period, or if varies by performance measure, describe: |
[Free Text] |
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| Other comments related to this submission (optional): |
[Free Text] |
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| Click the navigation bar or a tab at the bottom of the workbook to jump to the corresponding worksheet. |
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| Instructions: |
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| You may use this template to prepare a STD PCHD Performance Measures for DSTDP. Please refer to the supplemental guidance document for more information. |
| Complete each tab in this workbook, except for those labeled "optional." |
| Applicants will complete and submit performance measures each year, depending on approval from OMB. |
If you need technical support at any time, please send an email with a detailed description of your need to the following address:
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| [email protected] |
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| Notes on Data Entry: |
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| All light yellow cells are available for user input. White cells are auto-calculated based on information provided in the yellow cells. |
| Drop-down menus are included in all worksheets, and should be identifiable through a downward arrow that appears when you select it. |
| The core performance measures in each worksheet are bolded. Measures that are auto-calcuated but not considered core performance measures are italicized (not bolded). |
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| Saving and Submitting Your Work: |
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| Click "File" from the ribbon above and then "Save" from the menu. If this is your first time saving this document, you will be prompted to choose a location for where this file will be saved. Please save this file as "[ProjectAreaName]_Performance.Measures.2019_yy-mm-dd" and as an .xlsm version. (Note: you will see a warning message reminding you that if you change the format of the document, you may lose some of the functionality. Click "Ok" and save the file in your preferred location.) |
| Click "File" from the ribbon above and then "Save As" from the menu or use the button below. Choose the .xls or .xlsx file type from the "Save as type" drop-down menu. You will see a warning sign that says "The following features cannot be saved in macro-free workbooks: VB project". Click "Yes" to save the file as a .xls or .xlsx file type. You will still be able to edit light yellow cells, but a few features from this workbook will no longer be available. |
| To submit this document, attach the file ending in .xls or .xlsx as a Grant Note in GrantSolutions. |
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| Relevant Links: |
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| To access the series of Technical Assistance Notes for the PS19-1901 STD PCHD strategies, click here: |
| PS19-1901 STD PCHD Technical Assistance Notes |
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| To find general information on using Microsoft Excel, click here: |
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| Microsoft Excel Basics |
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| Reporting Burden |
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This information is collected under the authority of the Public Health Service Act, Section 301, "Research and Investigation," (42 U.S.C. 241); and Sections 304, 306 and 308(d) which discuss authority to maintain data and provide assurances of confidentiality for health research and related activities (42 U.S.C. 242 b, k, and m(d)). This information is also being collected in conjunction with the provisions of the Government Paperwork Elimination Act and the Paperwork Reduction Act (PRA). This information will only be used by the Centers for Disease Control and Prevention (CDC) staff to monitor recipient’s progress under cooperative agreement PS19-1901 STD PCHD.
Public reporting burden of this collection of information is estimated to average 30 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; Attn: OMB-PRA (0920-1282)
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| Surveillance |
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| Line No. |
Enhanced GC surveillance |
Data Fields |
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| a_1 |
Did your project area complete follow-up of any GC cases for any enhanced GC surveillance purposes (Strategy 2b) in the reporting period? |
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drop down menu |
| a_2 |
If yes (a_1), what geographic area(s) were included in the enhanced GC surveillance activities? |
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text field |
| a_3 |
Out of 12 months in the reporting period, what dates did your project area conduct enhanced GC surveillance? |
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| a_4 |
Total # of GC cases that were reported in that time period (a_3) and in that geographic area (a_2) |
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| a_5 |
Among those (a_4), # of GC cases that were randomly selected for enhanced surveillance |
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| a_6 |
Among those (a_5), # that received provider and/or patient follow-up for enhanced surveillance |
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| a_7 |
Among GC cases sampled for enhanced surveillance follow-up, % that received provider and/or patient follow-up |
#DIV/0! |
auto-calculated |
| a_8 |
Low or poor data quality? |
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drop down menu |
| a_9 |
Any data limitations, including reasons unable to report |
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text field |
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Pregnancy Ascertainment |
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| a_10 |
Total # of female syphilis cases (all stages) |
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| a_11 |
Total # of female syphilis cases (all stages) with pregnancy status documented as "Yes, pregnant" |
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| a_12 |
Total # of female syphilis cases (all stages) with pregnancy status documented as "No, not pregnant" |
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| a_13 |
Total # of female syphilis cases (all stages) with pregnancy status documented as "Unknown" or “Missing” |
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| a_14 |
Proportion of female syphilis cases (all stages) that had pregnancy status documented as "Yes, pregnant" or "No, not pregnant" |
#DIV/0! |
auto-calculated |
| a_15 |
Is your surveillance and/or case management system able to document when pregnancy status was obtained? |
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drop down menu |
| a_16 |
If yes (a_15): Total # of female syphilis cases (all stages) with pregnancy status documented as "Yes, pregnant" or "No, not pregnant" within 14 days of specimen collection |
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| a_17 |
Among all female syphilis cases (all stages), % with pregnancy status documented as “Yes, pregnant” or “No, not pregnant” within 14 days of specimen collection |
#DIV/0! |
auto-calculated |
| a_18 |
Low or poor data quality? |
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drop down menu |
| a_19 |
Any data limitations, including reasons unable to report |
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text field |
| Outbreak response |
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| Line No. |
Disease Investigation and Intervention |
Data Fields |
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Activation of STD outbreak response plan |
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| c_1 |
Total # of times that the outbreak plan was initiated for syphilis by the project area in the reporting period |
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| c_2 |
Total # of times that the outbreak plan was initiated for GC in the reporting period |
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| c_3 |
Total # of times that the outbreak plan was initiated for another STD in the reporting period |
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| c_4 |
Total # of times that the outbreak plan was initiated for an STD |
0 |
auto-calculated |
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Staff assignments to assist other outbreaks |
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| c_5 |
Total # of the STD program staff who were given temporary, formal assignments to assist with outbreaks with HIV, Hepatitis, or TB, during the reporting period |
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| c_6 |
Total # of STD program staff who were given temporary, formal assignments to assist with outbreaks with other conditions (not STD, HIV, Hepatitis, TB) during the reporting period |
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| c_7 |
Total # of STD staff deployed for non-STD outbreaks |
0 |
auto-calculated |
| c_8 |
Total # of outbreak responses (HIV, Hepatitis, TB, or other conditions) for which those staff were formally assigned to assist. |
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Data quality |
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| c_9 |
Low or poor data quality? |
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drop down menu |
| c_10 |
Any data limitations, including reasons unable to report |
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text field |
| Early Syphilis Cases: Disease Investigation and Intervention |
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| Line No. |
Key Populations: |
Pregnant females under age 45 |
Other females under age 45 |
Men with only female partners (MSW) |
Men with male partners (MSM and MSMW) |
Sum Totals (auto-calculated) |
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| d_1 |
Total # of early syphilis cases by the project area in the reporting period |
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0 |
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| d_2 |
Total # of cases initiated |
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0 |
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| d_3 |
Total # of cases interviewed |
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0 |
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| d_4 |
Interview Rate |
#DIV/0! |
#DIV/0! |
#DIV/0! |
#DIV/0! |
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auto-calculated |
| d_5 |
Total # of contacts (partners) initiated for partner services |
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0 |
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| d_6 |
Contact Index |
#DIV/0! |
#DIV/0! |
#DIV/0! |
#DIV/0! |
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auto-calculated |
| d_7 |
Total # of contacts examined (tested) within 30 days before or after the index patient’s initial specimen collection (Dispo A, B, C, D, E, F, Z) |
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0 |
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| d_8 |
New Exam Rate |
#DIV/0! |
#DIV/0! |
#DIV/0! |
#DIV/0! |
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auto-calculated |
| d_9 |
Total # of contacts previously treated (Dispo E) within 30 days before or after the index patient's initial specimen collection |
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0 |
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| d_10 |
Total # of contacts preventively treated (Dispo A) within 30 days before or after the index patient's initial specimen collection |
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0 |
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| d_11 |
Total # of contacts preventively treated (Dispo Z) within 30 days before or after the index patient's initial specimen collection |
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0 |
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| d_12 |
Total # of contacts brought to Tx for new syphilis infection (Dispo C) within 30 days after the index patient's initial specimen collection |
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0 |
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| d_13 |
Treatment Index |
#DIV/0! |
#DIV/0! |
#DIV/0! |
#DIV/0! |
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auto-calculated |
| d_14 |
Total # of cases w/at least 1 contact treated for syphilis (Dispo A, C, E, Z) within 30 days before or after the index patient’s initial specimen collection |
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0 |
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| d_15 |
Disease intervention rate |
#DIV/0! |
#DIV/0! |
#DIV/0! |
#DIV/0! |
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auto-calculated |
| d_16 |
Total number of contacts (partners) brought to treatment |
0 |
0 |
0 |
0 |
0 |
auto-calculated |
| d_17 |
Total number of new cases of syphilis found through partner services |
0 |
0 |
0 |
0 |
0.00 |
auto-calculated |
| d_18 |
Low or poor data quality? |
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drop down menu |
| d_19 |
Any data limitations, including reasons unable to report |
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text field |
| Line No |
STD -related HIV Prevention in Disease Investigation |
Syphilis Cases, by priority population |
MSM GC Cases (If any investigated) |
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| e_1 |
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Pregnant females under age 45 with early syphilis |
Other females under age 45 with early syphilis |
Men with only female partners (MSW) with early syphilis |
Men with male partners (MSM and MSMW) with early syphilis |
Men with male partners (MSM and MSMW) with GC cases only |
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| e_2 |
Total # of cases in the project area in the reporting period |
0 |
0 |
0 |
0 |
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prepopulated from sheets D and E |
| e_3 |
Total # of cases initiated |
0 |
0 |
0 |
0 |
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prepopulated from sheets D and E |
| e_4 |
Total # of cases interviewed |
0 |
0 |
0 |
0 |
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prepopulated from sheets D and E |
| e_5 |
Of interviewed, # known to be living with HIV at the time of syphilis (of GC) diagnosis |
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| e_6 |
Of interviewed, # newly-diagnosed with HIV within 30 days of syphilis (or GC) diagnosis |
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| e_7 |
Of syphilis (or GC) cases newly diagnosed with HIV, # linked to HIV care within 30 days of new HIV diagnosis |
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| e_8 |
Of interviewed, # referred for PrEP within 30 days of syphilis (or GC) diagnosis |
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| e_9 |
Among interviewed, (known) HIV coinfection rate |
0 |
#DIV/0! |
0 |
0 |
#DIV/0! |
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| e_10 |
Among interviewed syphilis or GC cases (and not known to be HIV+), % newly-diagnosed with HIV within 30 days of syphilis (or GC) diagnosis |
0 |
#DIV/0! |
#DIV/0! |
#DIV/0! |
#DIV/0! |
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| e_11 |
Low or poor data quality |
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drop down menu |
| e_12 |
Any data limitations, including reasons unable to report |
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text field |
| e_13 |
Among interviewed and newly diagnosed with HIV, % linked to HIV care within 30 days of new HIV diagnosis |
#DIV/0! |
#DIV/0! |
#DIV/0! |
#DIV/0! |
#DIV/0! |
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| e_14 |
Low or poor data quality? |
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drop down menu |
| e_15 |
Any data limitations, including reasons unable to report |
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text field |
| e_16 |
Among interviewed (and not known to be HIV+), % referred for PrEP within 30 days of syphilis (or GC) diagnosis |
0 |
#DIV/0! |
#DIV/0! |
#DIV/0! |
#DIV/0! |
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| e_17 |
Low or poor data quality? |
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drop down menu |
| e_18 |
Any data limitations, including reasons unable to report |
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text field |
| Treatment |
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| Line No. |
Recommended Treatment for syphilis |
Data Fields |
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| f_1 |
Total # of early syphilis (ES) cases in the project area in the reporting period |
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| f_2 |
Total # of early syphilis cases missing data on medication |
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| f_3 |
Total # of early syphilis cases missing data on medication AND date of treatment or date of specimen collection (unable to calculate timeliness of treatment) |
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| f_4 |
% of early syphilis cases missing documentation of medication |
#DIV/0! |
auto calculated |
| f_5 |
% of early syphilis cases missing data to calculate timely treatment AND documentation of medication |
#DIV/0! |
auto calculated |
| f_6 |
Total # of early syphilis cases documented as having been prescribed/received BPG within 14 days of date of specimen collection |
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| f_7 |
Among early syphilis cases, % treated by BPG within 14 days of specimen collection |
#DIV/0! |
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| f_8 |
Low or poor data quality? |
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drop down menu |
| f_9 |
Any data limitations, including reasons unable to report |
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text |
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Recommended Treatment for Gonorrhea |
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| f_10 |
For this measure, is the project area reporting on all cases or a random sample of cases, based on enhanced GC surveillance? If neither, explain below in Data Notes (g_21) |
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drop down |
| f_11 |
Total # of GC cases reported in the reporting period (Overall or in random sample) |
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| f_12 |
Total # of GC cases missing data on medication (among all or among random sample) |
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| f_13 |
Total # of GC cases missing data on medication AND date of treatment or date of specimen collection(among all or among random sample) |
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| f_14 |
% of GC cases missing documentation of medication (among all or among random sample) |
#DIV/0! |
auto calculated |
| f_15 |
% of GC cases missing data to calculate timely treatment AND documentation of medication (among all or among random sample) |
#DIV/0! |
auto calculated |
| f_16 |
Total # of GC cases with recommended medication (in 2019: dual therapy) documented (among all or among random sample) |
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| f_17 |
Total # of GC cases with recommended medication (in 2019: dual therapy) documented as having been prescribed/received within 14 days of date of specimen collection (among all or among random sample) |
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| f_18 |
Among all GC cases, % with recommended medication documented, per CDC guidance (among all or among random sample) |
#DIV/0! |
auto calculated |
| f_19 |
Among all GC cases, % with recommended medication documented within 14 days of the date of specimen collection, per CDC guidance (among all or among random sample) |
#DIV/0! |
auto calculated |
| f_20 |
Low or poor data quality? |
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drop down menu |
| f_21 |
Any data limitations, including reasons unable to report |
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text |
| General Description of Safety Net Assistance (SNA) |
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| Line No. |
Description |
Data Fields |
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| sna_1 |
Approximately what % of the STD PCHD budget did the project area devote to safety net assistance in the reporting period? |
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all drop down menus unless noted as "text" |
| sna_2 |
Did the project area specifically focus the safety net assistance towards any of the following demographic groups? (select all that apply) |
Adolescents/young adults |
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| sna_3 |
MSM |
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| sna_4 |
Pregnant women |
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| sna_5 |
No, none of these groups were specifically focused on (though they may have benefited) |
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| sna_6 |
What were the main formal criteria used for selecting which providers or organizations were eligible to access the safety net assistance (SNA) or were funded for SNA? (select all that apply) |
They met a certain threshold for positivity for testing |
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| sna_7 |
They met a certain threshold for STD disease morbidity or a certain STD case count or rate |
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| sna_8 |
They served under/uninsured populations |
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| sna_9 |
They served other priority populations or geographic areas in need of subsidized services |
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| sna_10 |
They had a track record of effective partnership with us |
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| sna_11 |
I’m not sure/don’t know |
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| sna_12 |
Other: (please write answer below in sna_45 text box) |
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| sna_13 |
Which STD clinical prevention services did the safety net assistance support? Select all that apply. |
CT/GC urine testing/screening |
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| sna_14 |
CT/GC extragenital testing/screening |
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| sna_15 |
CT/GC treatment, including EPT |
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| sna_16 |
Syphilis testing/screening |
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| sna_17 |
Syphilis treatment |
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| sna_18 |
Other STD clinical preventive service: (please write answer below in sna_45 text box) |
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| sna_19 |
Which types of providers were funded directly by the project area for safety net assistance (SNA) or were given the opportunity to take advantage of the SNA during the reporting period? Select all that apply. |
STD specialty care clinics |
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| sna_20 |
Local health department clinics (general) |
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| sna_21 |
Family planning/ reproductive health clinics |
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| sna_22 |
Maternal and child health programs |
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| sna_23 |
HIV prevention or care clinics |
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| sna_24 |
Behavioral or mental health agencies, including drug treatment |
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| sna_25 |
Federally-qualified health centers (FQHC) or other community health centers |
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| sna_28 |
Correctional facilities (prison, jail, juvenile detention) |
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| sna_29 |
School-based, college, or university health centers |
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| sna_30 |
Tribal or Indian Health Service health care centers |
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Other non-profit, private health care providers or organizations (e.g., CBOs) |
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Other private health care providers or organizations |
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| sna_31 |
Others not listed: (please write answer below in sna_45 text box) |
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| sna_32 |
We don’t know/ aren’t sure |
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What are the primary mechanisms through which the project area provided the safety net assistance (SNA)? Select all that apply. |
Often found in Contract budget line: |
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| sna_33 |
(A) Direct contracts or subgrants with health care organizations or providers for safety net assistance only |
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| sna_34 |
(B) Direct contracts or subgrants with health care organizations or providers for various services that include safety net assistance |
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| sna_35 |
(C) Direct contracts or subgrants with lab(s) (public or private) to conduct testing for certain providers |
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Often found in Supplies, Other, or Personnel: |
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| sna_36 |
(D) Purchase of test kits or treatment/EPT, which are then distributed or allocated to certain providers by us |
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| sna_37 |
(E) Support all/part of the salary of lab(s) staff to conduct testing for certain providers or types of tests |
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| sna_38 |
(F) Other: (please write answer below in sna_45 text box) |
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| sna_39 |
Did the project area combine the STD PCHD safety net assistance with funding from other sources, to fund those contracts/ subgrants (A-C), to make those purchases (D), or support those staff (E)? Select all that apply. |
Yes, we added state (or local) project area funds (e.g. STD, general) |
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| sna_40 |
Yes, we added federal funds (e.g. HIV, Title X, HRSA) |
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| sna_41 |
Yes, we added other funding sources |
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| sna_42 |
No, STD PCHD was the only funding we put into those contracts/subgrants/purchases |
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| sna_43 |
Don't know/ too unsure to answer |
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(Optional) Please provide any other information you would like to add about your approach to providing SNA in the reporting period, or answers to question on this worksheet for which you selected "Other": |
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| sna_44 |
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text |
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For which parts of your safety net assistance do you have data on tests conducted, test results, or treatment purchased? |
Often found in Contract budget line: |
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| sna_45 |
(A) Direct contracts or subgrants with health care organizations or providers for safety net assistance only |
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| sna_46 |
(B) Direct contracts or subgrants with health care organizations or providers for various services that include safety net assistance |
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| sna_47 |
(C) Direct contracts or subgrants with lab(s) (public or private) to conduct testing for certain providers |
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Often found in Supplies, Other, or Personnel: |
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| sna_48 |
(D) Purchase of test kits or treatment/EPT, which are then distributed or allocated to certain providers by us |
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| sna_49 |
(E) Support all/part of the salary of lab(s) staff to conduct testing for certain providers or types of tests |
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| sna_50 |
(F) Other: (please write answer below in line s) |
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| sna_51 |
We do not have any data at this time (please provide reason why not, above in sna_45 text box) |
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| If A-F is selected, please complete an "Admin_SNA_test_TX_data" worksheet for each mechanism selected. Up to 3 total. |
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