STD PCHD PM Data Collection Tool

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Draft for STD PCHD Project Areas' Review Only

12/13/2019

Form Approved
OMB No. 0920-1282
STD PCHD Performance Measurement
Year 5

Expiration Date: TBD

Project Area (Select from dropdown):
Period of Performance:

January 1, 2024 to December 31, 2024

Submission Date (mm/dd/yyyy):
If other reporting period, or if varies by
performance measure, describe:
Other comments related to this submission
(optional):
Click a tab at the bottom of the workbook to jump to the corresponding worksheet.

Instructions:
Please use this template to prepare a STD PCHD Performance Measures submission for DSTDP. There is an optional "Feedback" tab we have provided for you to comment on
the updates the STD PCHD Team has made to this template. Please refer to the supplemental guidance document for information on the rationale for requesting these data,
how the data will be used, and how to complete each worksheet. Furthermore, the supplemental guidance document indicates where there are changes to either the
variable requested or clarifications made on how to report on a specific variable.
Applicants will complete and submit performance measures each year.
If you need technical support at any time, please send an email with a detailed description of your need to the following address:
[email protected]
Notes on Data Entry:

Draft for STD PCHD Project Areas' Review Only

All light pink cells are available for user input. Please
complete them to the best of your ability.

12/13/2019

Gray cells are auto-calculated or pre-populated based on
information provided.

Drop-down menus are included in all worksheets, and they 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).
kkk
Saving and Submitting Your Work:
Please save this file as "[ProjectAreaName]_Performance.Measures.2023_yy-mm-dd" and as an .xlsm version. (Note: if you save this file as an .xls or .xlsx document type, the
template may no longer automatically expand and collapse the height of rows to fit text.)
To submit this document, save a copy of the file ending in .xls or .xlsx as a Grant Note in GrantSolutions by the deadline provided by DSTDP. Please submit a courtesy copy to
your DSTDP project officer as well by October 7, 2024.
Relevant Links:
To access the series of Technical Assistance Notes for the PS19-1901 STD PCHD strategies, click here:
PS19-1901 STD PCHD Technical Assistance Notes
To find general information on using Microsoft Excel:
Microsoft
click here: Excel Basics
Privacy Act Statement and Reporting Burden
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).

Draft for STD PCHD Project Areas' Review Only

12/13/2019

Surveillance
Line No.

Pregnancy Ascertainment

Data Fields

a_10

Total number of female syphilis cases (all stages) reported
in the project area in the reporting period

0

a_11

Total number of female syphilis cases (all stages) with
pregnancy status documented as "Yes, pregnant"

a_12

Total number of female syphilis cases (all stages) with
pregnancy status documented as "No, not pregnant"

a_13

Total number of female syphilis cases (all stages) with
pregnancy status documented as "Unknown" or “Missing”

a_14

Percent of female syphilis cases (all stages) that had
pregnancy status documented as "Yes, pregnant" or "No, not
pregnant"

a_15

Is your surveillance and/or case management system able
to document when pregnancy status was obtained?

a_16

If yes (a_15): Total number of female syphilis cases (all
stages) with pregnancy status documented as "Yes,
pregnant" or "No, not pregnant" within 14 days of
specimen collection

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

a_18

Indicate the quality of the data above by selecting an
answer from the dropdown menu.

a_19

Any data limitations, including reasons unable to report
(text response)

Enter Denominator

Enter Denominator

Draft for STD PCHD Project Areas' Review Only

12/13/2019

Congenital Syphilis
Line No.

Potential Cases Averted

Data Fields

b_1

Total number of females with syphilis (all stages) in the project area in the reporting
0
period. (To reference this value, clic

b_2

Total number of pregnant females with syphilis (all stages). (To reference this value,
0
click this link.)

b_3

% of total female syphilis cases that were pregnant

b_4

Total number of reported congenital syphilis cases and
stillbirths

b_5

Total number of potential congenital syphilis cases averted

Enter Denominator

0

Draft for STD PCHD Project Areas' Review Only

b_6

Among all potential congenital syphilis cases, % averted

b_7

Indicate the quality of the data above by selecting an answer
from the dropdown menu.

b_8

Any data limitations, including reasons unable to report (text
response)

12/13/2019

Enter Denominator

Draft for STD PCHD Project Areas' Review Only

12/13/2019

Outbreak Response
Line No.

Disease Investigation and Intervention

Active or Initiated STD Outbreak Response Plan(s)

c_1

Does the project area have an STD outbreak plan in
place? [Select from dropdown. If no, please skip to the
section“Staff assignments to assist other outbreaks”
(c_6)]

c_2

Total number of times that the outbreak plan was active
or initiated for syphilis by the project area in the
reporting period

c_3

Total number of times that the outbreak plan was active
or initiated for GC in the reporting period

c_4

Total number of times that the outbreak plan was active
or initiated for another STD in the reporting period

Data Fields

Draft for STD PCHD Project Areas' Review Only

12/13/2019

c_5

Total number of times that the outbreak plan was
active or initiated for an STD

0

Line No.

Staff Deployments to Assist Other Outbreaks

Data Fields

c_6

Total number of STD program staff deployed on
temporary, formal assignments to assist with HIV,
Hepatitis, or TB outbreaks during the reporting period

c_7

Total number of STD program staff deployed on
temporary, formal assignments to assist with non-STD
(e.g. foodborne, etc.) outbreaks during the reporting
period

c_8

Total number of STD staff deployed for all outbreaks of
all types (STD and non-STD)

0

c_8a

Among all STD program staff deployed, % STD staff
deployed for a non-STD outbreak

Enter Denominator

c_9

Total number of outbreak responses (HIV, Hepatitis, TB,
or other conditions) for which those staff were formally
assigned to assist during the period.

Draft for STD PCHD Project Areas' Review Only

Line No.

Data Quality

c_10

Indicate the quality of the data above by selecting an
answer from the dropdown menu.

c_11

Any data limitations, including reasons unable to report
(text response)

12/13/2019

Data Fields

Draft for STD PCHD Project Areas' Review Only

12/13/2019

Early Syphilis Cases: Disease Investigation and Intervention
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 (autocalculated)

Line No.

Key Populations

d_1

Total number of early syphilis cases by the project
area in the reporting period

0

d_2

Total number of cases initiated

0

d_3

Total number of cases interviewed

0

d_4

Interview Rate

d_5

Total number of contacts (partners) initiated for
partner services

d_6

Contact Index

d_7

Total number 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)

d_8

Exam Rate

d_9

Total number of contacts previously treated (Dispo
E) within 30 days before or after the index patient's
initial specimen collection

Enter Denominator

Enter Denominator

Enter Denominator

Enter Denominator

0

Enter Denominator

Enter Denominator

Enter Denominator

Enter Denominator

0

Enter Denominator

Enter Denominator

Enter Denominator

Enter Denominator

0

Draft for STD PCHD Project Areas' Review Only

12/13/2019

d_10

Total number of contacts preventively treated
(Dispo A) within 30 days before or after the index
patient's initial specimen collection

0

d_11

Total number of contacts preventively treated
(Dispo Z) within 30 days before or after the index
patient's initial specimen collection

0

d_12

Total number of contacts brought to Tx for new
syphilis infection (Dispo C) within 30 days after the
index patient's initial specimen collection

0

d_13

Treatment Index

d_14

Total number of cases interviewed w/at least 1
contact (partner) treated for syphilis (Dispo A, C, E,
Z) within 30 days before or after the index patient’s
initial specimen collection

d_15

Disease Intervention Rate

Enter Denominator

Enter Denominator

Enter Denominator

Enter Denominator

0

Enter Denominator

Enter Denominator

Enter Denominator

Enter Denominator

Enter Denominator

d_16

0 from d_12. To reference
0 this value, click this link.)
0
Total number of partners brought to treatment (Pre-populated

0

0

d_17

Total number of new cases of syphilis found through
partner services

0

0

d_18

Indicate the quality of the data above by selecting
an answer from the dropdown menu. (select your
answer twice)

d_19

Any data limitations, including reasons unable to
report (text response)

0

0

0

Draft for STD PCHD Project Areas' Review Only

12/13/2019

STD-Related HIV Prevention in Disease Investigation

Line No.

Metric

Pregnant Females under
Age 45 with Early Syphilis

Other Females under
Age 45 with Early
Syphilis

Men with Male
Partners (MSM and
MSMW) with Early
Syphilis

Men with Only Female
Partners (MSW) with
Early Syphilis

Men with Male Partners
(MSM and MSMW) with
GC

e_1

0
Total number of cases in the project area in the reporting period (Pre-populated
from d_1 on tab 0D. To reference this value,0 click this link.)

0

e_2

0
0 link.)
Total number of cases initiated (Pre-populated from d_2 on tab D. To reference
this value, click this

0

0

e_3

0 reference this value, click0 this link.)
Total number of cases interviewed (Pre-populated from d_3 on tab D. To

0

0

e_4

Of interviewed, number known to be living with HIV
at the time of syphilis (or GC) diagnosis

e_5

Of interviewed, number newly-diagnosed with HIV
within 30 days after syphilis (or GC) diagnosis

e_6

Among interviewed, overall HIV coinfection rate

Enter Denominator

Enter Denominator

Enter Denominator

Enter Denominator

Enter Denominator

e_7

Among interviewed syphilis or GC cases (and not
known to be HIV+), % newly-diagnosed with HIV
within 30 days after syphilis (or GC) diagnosis

Enter Denominator

Enter Denominator

Enter Denominator

Enter Denominator

Enter Denominator

e_8

Indicate the quality of the data above by selecting an
answer from the dropdown menu. (select your
answer twice)

e_9

Any data limitations, including reasons unable to
report (text response)

Draft for STD PCHD Project Areas' Review Only

e_10

Of syphilis (or GC) cases newly diagnosed with HIV
(e_5), number linked to HIV care within 30 days after
new HIV diagnosis

e_11

Among interviewed and newly diagnosed with
HIV, % linked to HIV care within 30 days after new
HIV diagnosis

e_12

Indicate the quality of the data above by selecting an
answer from the dropdown menu. (select your
answer twice)

e_13

Any data limitations, including reasons unable to
report (text response)

e_14

Of interviewed (and not known to be HIV+), number
referred for PrEP after syphilis (or GC) diagnosis

e_15

Among interviewed (and not known to be HIV+), %
referred for PrEP after syphilis (or GC) diagnosis

e_16

Indicate the quality of the data above by selecting an
answer from the dropdown menu. (select your
answer twice)

e_17

Any data limitations, including reasons unable to
report (text response)

12/13/2019

Enter Denominator

Enter Denominator

Enter Denominator

Enter Denominator

Enter Denominator

Enter Denominator

Enter Denominator

Enter Denominator

Enter Denominator

Enter Denominator

Draft for STD PCHD Project Areas' Review Only

12/13/2019

Treatment
Line No.

Recommended Treatment for Gonorrhea

f_1

For this measure, is the project area reporting on all cases
or a sample of cases, based on enhanced GC surveillance?
If neither, explain below in Data Notes (f_12) (select from
dropdown)

f_2

Total number of GC cases reported in the reporting period
(Overall or among a sample)

f_7

Total number of GC cases with recommended medication
documented (among all or among a sample)

f_8

Total number of GC cases with recommended medication
documented as having been prescribed/received within 14
days of date of specimen collection (among all or among a
sample)

f_9

Among all GC cases, % with recommended medication
documented, per CDC guidance (among all or among a
sample)

Data Fields

Enter Denominator

Draft for STD PCHD Project Areas' Review Only

f_10

Among all GC cases, % with recommended medication
documented within 14 days of the date of specimen
collection, per CDC guidance (among all or among a
sample)

f_11

Indicate the quality of the data above by selecting an
answer from the dropdown menu.

f_12

Any data limitations, including reasons unable to report
(text response)

Line No.

Recommended Treatment for Syphilis

f_13

Total number of early syphilis (ES) cases in the project area
in the reporting period

f_18

Total number of early syphilis cases documented as
having been prescribed/received BPG within 14 days of
date of specimen collection

f_18a

(New) Total number of early syphilis cases documented as
having been prescribed/received treatment with
Doxycycline within 14 days of specimen collection

12/13/2019

Enter Denominator

Data Fields

Draft for STD PCHD Project Areas' Review Only

12/13/2019

f_19

Among early syphilis cases, % treated with BPG within
14 days of specimen collection

Enter Denominator

f_19a

(New) Among early syphilis cases, % treated with
Doxycycline within 14 days of specimen collection

Enter Denominator

f_20

Indicate the quality of the data above by selecting an
answer from the dropdown menu.

f_21

Any data limitations, including reasons unable to report
(text response)

Purpose:
• The purpose of this dynamic dashboard is to provide you a sense of your jurisdiction's performance live while updating this template a

Helpful Tips:
• Keep checking this tab as you complete this Excel template to get a more complete picture of your performance for this reporting peri
• If you want to refer back to the exact part of the template from which the data for a particular visual originated, click the link above th

Instructions for Use:
• Simply right-click on any visual and click "Copy" (or click on the visual and use the ctrl+c keyboard shortcut).
• Open another file, such as a Microsoft Word document or Microsoft PowerPoint presentation.
• Right-click anywhere in that file and click "Paste" (or use the ctrl+v keyboard shortcut).
• Once pasted, click the dropdown next to the clipboard icon labeled "Ctrl" (or use the ctrl+alt+v keyboard shortcut) to choose the forma

Tab A_Surveillance
Pregnancy Ascertainment

Total Number of Female Syphilis Cases by
Pregnancy Status

Total Number of Female Syphilis Cases by
Pregnancy Status

Total number of female syphilis cases (all stages)
0
reported in the project area in the reporting period

If yes (a_15): Total number of female syphilis cases (all
stages) with pregnancy status documented as "Yes,
pregnant" or "No, not pregnant" within 14 days of
specimen collection

Key Takeaway: Quickly ascertaining pregnancy status allows your
program to prioritize these cases for follow-up and provide more timely
case managment. Among all female syphilis cases (all stages), the
percent with a pregnancy status documented within 14 days of specimen
collection is:

Enter Denominator

At-a-Glance

ense of your jurisdiction's performance live while updating this template and to provide you an instant visual ready to use in your own reporti

o get a more complete picture of your performance for this reporting period.
om which the data for a particular visual originated, click the link above the visual.

he visual and use the ctrl+c keyboard shortcut).
icrosoft PowerPoint presentation.
ctrl+v keyboard shortcut).
abeled "Ctrl" (or use the ctrl+alt+v keyboard shortcut) to choose the format and type of object (e.g. Microsoft Office Graphic Object vs .JPEG pic

Tab B_Congenital Syphilis
Potential Cases Averted

Total Number of Congenital Syphilis
Cases and Stillbirths of all Potential
Congenital Syphilis Cases

Total Number and Percent of Times that
the Outbreak Plan was Active or Initiated
by STD

Total Number of Congenital Syphilis
Cases and Stillbirths of all Potential
Congenital Syphilis Cases

Total number of females with syphilis (all stages) in
the project area in the reporting period. (To
reference this value, click this link.)

Total number of pregnant females with syphilis (all
stages). (To reference this value, click this link.)

Total number of reported congenital syphilis cases
and stillbirths

Key Takeaway: The best way to prevent potential cases of congenital
syphilis is to prevent syphilis cases in women in general. Continue to
assess syphilis cases among women and CS cases for gaps in syphilis
testing and treatment and seek to improve. Among all potential
congenital syphilis cases, the percent averted is:

Enter Denominator

Total Number and Percent of Times that
the Outbreak Plan was Active or Initiated
by STD
Total number of times that
the outbreak plan was active
or initiated for syphilis by the
project area in the reporting
period

Total number of times that
the outbreak plan was active
or initiated for GC in the
reporting period

Total number of times that
the outbreak plan was active
or initiated for another STD in
the reporting period

At-a-Glance Dashboard

plate and to provide you an instant visual ready to use in your own reporting and documentation.

ng period.
ove the visual.

format and type of object (e.g. Microsoft Office Graphic Object vs .JPEG picture, etc.) of the visual as you would like it pasted into your docume

Tab C_Outbreak
Active or Initiated STD Outbreak Response Plan(s)

Total Number and Percent of Times that
the Outbreak Plan was Active or Initiated
by STD

Total Number and Percent of Times that
the Outbreak Plan was Active or Initiated
by STD
Total number of times that
the outbreak plan was active
or initiated for syphilis by the
project area in the reporting
period

Total number of times that
the outbreak plan was active
or initiated for GC in the
reporting period

Total number of times that
the outbreak plan was active
or initiated for another STD in
the reporting period

Key Takeaway: This visual depicts the total number and percent of times
an outbreak plan was active or initiated for various STDs in this reporting
period.

Staff Assignments to Assist Other Outbreaks

Total Number and Percent of STD Staff
Who were Deployed for All Outbreaks
(STD and Non-STD)
Total number of STD
program staff deployed on
temporary, formal
assignments to assist with
HIV, Hepatitis, or TB
outbreaks during the
reporting period
Total number of STD
program staff deployed on
temporary, formal
assignments to assist with
non-STD (e.g. foodborne,
etc.) outbreaks during the
reporting period

Disease Intervention Rate by Key
Population

Men with Male Partners (MSM and
MSMW)

Men with only Female Partners (MSW)

Other Females under Age 45

Pregnant Females under Age 45

Key Takeaway: Among all STD program staff deployed to assist with
outbreaks, the percent of staff deployed for non-STD outbreaks in this
reporting period is:

Enter Denominator

Total Number of Priority Medical
Providers, including those Administering
DoxyPEP

Total number of Priority Medical Practices (STD
clinic/Non-STD Clinic) identified in jurisdiction

Total number of Priority Medical Practices (STD
clinic/Non-STD Clinic) identified in jurisdiction that
provide DoxyPEP to patients

Total number of Priority Medical Practices (STD
clinic/Non-STD Clinic) identified in jurisdiction that
provide DoxyPEP to patients

e Dashboard

reporting and documentation.

PEG picture, etc.) of the visual as you would like it pasted into your document or presentation.

Tab D_Syphilis DII
Early Syphilis Cases: Disease Investigation and Intervention

Total Number of Early Syphilis Cases
Interviewed, by Key Population

Among Interviewed Early Syphilis Cases
(and not known to be HIV+), Percent
Newly-Diagnosed with HIV within 30
days after Early Syphilis Diagnosis, by

Total Number of Early Syphilis Cases
Interviewed, by Key Population

Pregnant Females under Age 45

Among Interviewed Early Syphilis Cases
(and not known to be HIV+), Percent
Newly-Diagnosed with HIV within 30
days after Early Syphilis Diagnosis, by
Key Population

Total number of cases
interviewed
Other Females under Age 45

Total number of cases
initiated
Total number of early
syphilis cases by the
project area in the
reporting period

Pregnant Females under Age 45 with Early Syphilis

Other Females under Age 45 with Early Syphilis

Men with only Female Partners (MSW)
Men with Only Female Partners (MSW) with Early
Syphilis
Men with Male Partners (MSM and
MSMW)

Key Takeaway: The higher the number of cases interviewed, the greater
chance for contact elicitation, exam, and potential disease intervention.

Men with Male Partners (MSM and MSMW) with
Early Syphilis

on

Disease Intervention Rate

Disease Intervention Rate by Key
Population

Men with Male Partners (MSM and
MSMW)

Pregnant Females under Age 45 with Early Syphilis

th

Men with only Female Partners (MSW)
Other Females under Age 45 with Early Syphilis

on

th
,
he

Among Interviewed and Newly Diagnosed
with HIV, Percent Linked to HIV Care
within 30 Days after New HIV Diagnosis by
Key Population

Other Females under Age 45

Pregnant Females under Age 45

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 Early
Syphilis

Key Takeaway: The higher the Disease Intervention Rate (DIR), the more
your program intervened in the spread of syphilis. The Total DIR across
all key populations is:

Enter Denominator
DoxyPEP for Bacterial STI Prevention

Total Number of Priority Medical
Providers, including those Administering
DoxyPEP

Among Early Syphilis Cases Interviewed
(and not known to be HIV+), % Referred
for PrEP, by Key Population

Pregnant Females under Age 45 with Early Syphilis
Total number of Priority Medical Practices (STD
clinic/Non-STD Clinic) identified in jurisdiction
Other Females under Age 45 with Early Syphilis

Total number of Priority Medical Practices (STD
clinic/Non-STD Clinic) identified in jurisdiction that
provide DoxyPEP to patients

Men with Only Female Partners (MSW) with Early
Syphilis

Men with Male Partners (MSM and MSMW) with
Early Syphilis

Total number of Priority Medical Practices (STD
clinic/Non-STD Clinic) identified in jurisdiction that
provide DoxyPEP to patients

Syphilis

Men with Male Partners (MSM and MSMW) with
Early Syphilis

Key Takeaway: The higher the percentage of Priority Medical Providers
(STD clinic/Non-STD Clinic) prescribing DoxyPEP to their patients, the
greater the chance of preventing bacterial STIs such as syphilis. The
percentage of Priority Medical Providers (STD clinic/Non-STD Clinic)
prescribing DoxyPEP in this reporting period is:

Enter Denominator

ocument or presentation.

Tab E_HIV Prevention DII
Newly Diagnosed HIV Cases Among Syphilis or GC Cases

Among Interviewed Early Syphilis Cases
(and not known to be HIV+), Percent
Newly-Diagnosed with HIV within 30
days after Early Syphilis Diagnosis, by

Total Number and Percent of Early
Syphilis Cases Treated with BPG or
Doxycycline

Among Interviewed Early Syphilis Cases
(and not known to be HIV+), Percent
Newly-Diagnosed with HIV within 30
days after Early Syphilis Diagnosis, by
Key Population
es
es

rly
e

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

Key Takeaway: The higher the newly HIV diagnosed percentage, the
more significant HIV testing of syphilis cases is to detecting HIV
infections and getting them linked to care to interupt transmission.

Total Number and Percent of Early
Syphilis Cases Treated with BPG or
Doxycycline

Total number of early syphilis
cases documented as having
been prescribed/received BPG
within 14 days of date of
specimen collection
(New) Total number of early
syphilis cases documented as
having been prescribed/
received treatment with
Doxycycline within 14 days of
specimen collection

HIV Linkage to Care

Among Interviewed and Newly Diagnosed
with HIV, Percent Linked to HIV Care
within 30 Days after New HIV Diagnosis by
Key Population

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 Early
Syphilis

Key Takeaway: The higher the HIV linkage to care percentage, the more
likely it is your program will prevent spread and progression of HIV to
AIDS.

PrEP Referral Percentage Post Syphilis Diagnosis

Among Early Syphilis Cases Interviewed
(and not known to be HIV+), % Referred
for PrEP, by Key Population

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

Syphilis

Men with Male Partners (MSM and MSMW) with
Early Syphilis

Key Takeaway: The higher the PrEP referral percentage, the greater the
chance of preventing the acquisition of HIV infection.

Tab F_Treatment
Recommended Treatment for Syphilis

Total Number and Percent of Early
Syphilis Cases Treated with BPG or
Doxycycline

Total Number and Percent of Early
Syphilis Cases Treated with BPG or
Doxycycline

Total number of early syphilis
cases documented as having
been prescribed/received BPG
within 14 days of date of
specimen collection
(New) Total number of early
syphilis cases documented as
having been prescribed/
received treatment with
Doxycycline within 14 days of
specimen collection

Key Takeaway: BPG is the recommended CDC treatment. A higher
percentage of early syphilis (ES) cases treated with BPG is optimal. The
percentage of ES cases treated with BPG is:

Enter Denominator

Draft for STD PCHD Project Areas' Review Only

12/13/2019

Optional Feedback
Line No.

Question

Response

q1

Did you find the notes and instructions provided for each
response useful? Please select your answer from the dropdown
menu.

q2

Did you find the UI improvements (e.g. color-coded data entry
and reference links) useful? Please select your answer from the
dropdown menu.

q3

Did you find the Dashboard tab useful? Please select your answer from the dropdown menu. (To reference the Dashboar

q4

Did you attempt to cut and paste the graphics from the Dashboard tab into another document? (To reference the Dashb

q5

Above, why or why not did you attempt to cut and paste the
graphics? If you answered yes to #3, briefly describe how that
process went for you. (text response)

Draft for STD PCHD Project Areas' Review Only

q6

Overall, please share any additional thoughts or feedback you
have about the template. (text response)

12/13/2019

Draft for STD PCHD Project Areas' Review Only

General Description of Safety Net Assistance (SNA)
Description

Line No
sna_1
sna_2
sna_3
sna_4
sna_5
sna_6
sna_7
sna_8
sna_9
sna_10
sna_11
sna_12
sna_13
sna_14
sna_15
sna_16
sna_17
sna_18
sna_19
sna_20
sna_21
sna_22
sna_23
sna_24
sna_25
sna_28
sna_29

Approximately what % of the STD
PCHD budget did the project area
devote to safety net assistance in the
reporting period?

12/13/2019

Data Fields
[Select from Dropdown]

Adolescents/young adults
Did the project area specifically focus MSM
the safety net assistance towards any Pregnant women
of the following demographic groups? No, none of these groups were specifically focused on (though
(select all that apply)
they may have benefited). (Select Yes only if sna_2, sna_3, and
sna_4 were all answered as No)
They met a certain threshold for positivity for testing
They met a certain threshold for STD disease morbidity or a
certain STD case count or rate
What were the main formal criteria
They served under/uninsured populations
used for selecting which providers or
They served other priority populations or geographic areas in
organizations were eligible to access
need of subsidized services
the safety net assistance (SNA) or
They had a track record of effective partnership with us
were funded for SNA? (select all that
Other: (please write answer below in sna_46 text box)
apply)
I'm not sure/don't know of the main formal criteria that was
used (If answered as Yes, please provide further context in
sna_46)
CT/GC urine testing/screening
CT/GC extragenital testing/screening
Which STD clinical prevention services CT/GC treatment, including EPT
did the safety net assistance support? Syphilis testing/screening
Select all that apply.
Syphilis treatment
Other STD clinical preventive service: (please write answer
below in sna_46 text box)
STD specialty care clinics
Local health department clinics (general)
Family planning/ reproductive health clinics
Maternal and child health programs
HIV prevention or care clinics

[Select from Dropdown]
[Select from Dropdown]
[Select from Dropdown]

Behavioral or mental health agencies, including drug treatment
Which types of providers were
funded directly by the project area for
Federally-qualified health centers (FQHC) or other community
safety net assistance (SNA) or were
health centers
given the opportunity to take
Correctional facilities (prison, jail, juvenile detention)
advantage of the SNA during the
School-based, college, or university health centers
reporting period? Select all that
apply.

[Select from Dropdown]

[Select from Dropdown]
[Select from Dropdown]
[Select from Dropdown]
[Select from Dropdown]
[Select from Dropdown]
[Select from Dropdown]
[Select from Dropdown]
[Select from Dropdown]
[Select from Dropdown]
[Select from Dropdown]
[Select from Dropdown]
[Select from Dropdown]
[Select from Dropdown]
[Select from Dropdown]
[Select from Dropdown]
[Select from Dropdown]
[Select from Dropdown]
[Select from Dropdown]
[Select from Dropdown]

[Select from Dropdown]
[Select from Dropdown]
[Select from Dropdown]

sna_30
sna_31
sna_32
sna_33
sna_34
sna_35
sna_36
sna_37

sna_38
sna_39
sna_40
sna_41
sna_42
sna_43
sna_44
sna_45

funded directly by the project area for
safety net assistance (SNA) or were
given the opportunity to take
Draft for STD PCHD Project Areas' Review Only
12/13/2019
advantage of the SNA during the
reporting period? Select all that
Tribal or Indian Health Service health care centers
[Select from Dropdown]
apply.
Other non-profit, private health care providers or
[Select from Dropdown]
organizations (e.g., CBOs)
Other private health care providers or organizations
[Select from Dropdown]
Others not listed: (please write answer below in sna_46 text
[Select from Dropdown]
box)
We don’t know/ aren’t sure
[Select from Dropdown]
Often found in Contract budget line:
(A) Direct contracts or subgrants with health care
[Select from Dropdown]
organizations or providers for safety net assistance only
(B) Direct contracts or subgrants with health care organizations
[Select from Dropdown]
or providers for various services that include safety net
assistance
What are the primary mechanisms
(C) Direct contracts or subgrants with lab(s) (public or private)
through which the project area
[Select from Dropdown]
to conduct testing for certain providers
provided the safety net assistance
(SNA)? Select all that apply.
Often found in Supplies, Other, or Personnel:
(D) Purchase of test kits or treatment/EPT, which are then
[Select from Dropdown]
distributed or allocated to certain providers by us
(E) Support all/part of the salary of lab(s) staff to conduct
[Select from Dropdown]
testing for certain providers or types of tests
(F) Other: (please write answer below in sna_46 text box)
[Select from Dropdown]
Yes, we added state (or local) project area funds (e.g. STD,
[Select from Dropdown]
Did the project area combine the STD general)
PCHD safety net assistance with
Yes, we added federal funds (e.g., HIV, Title X, HRSA)
[Select from Dropdown]
funding from other sources, to fund
Yes, we added other funding sources
[Select from Dropdown]
those contracts/ subgrants (A-C), to
No, STD PCHD was the only funding we put into those
make those purchases (D), or support
[Select from Dropdown]
contracts/subgrants/purchases
those staff (E)? Select all that apply.
Don't know/ too unsure to answer
[Select from Dropdown]
(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":

sna_46
Often found in Contract budget line:
(A) Direct contracts or subgrants with health care
[Select from Dropdown]
organizations or providers for safety net assistance only
(B) Direct contracts or subgrants with health care organizations
or providers for various services that include safety net
[Select from Dropdown]
assistance

sna_47
sna_48
For which parts of your safety net
assistance do you have data on tests
conducted, test results, or treatment
purchased?

Draft for STD PCHD Project Areas' Review Only

sna_49

sna_50
sna_51
sna_52
sna_53

(C) Direct contracts or subgrants with lab(s) (public or private)
For which parts of your safety net
[Select from Dropdown]
assistance do you have data on tests to conduct testing for certain providers
Often found in Supplies, Other, or Personnel:
conducted, test results, or treatment
purchased?
(D) Purchase of test kits or treatment/EPT, which are then
[Select from Dropdown]
distributed or allocated to certain providers by us
(E) Support all/part of the salary of lab(s) staff to conduct
[Select from Dropdown]
testing for certain providers or types of tests
[Select from Dropdown]
(F) Other: (please write answer above in sna_46 text box)
We do not have any data at this time (please provide reason
[Select from Dropdown]
why not, above in sna_46 text box)
If A-F is selected, please complete an "Admin_SNA_test_TX_data" worksheet for each mechanism selected. Up to 3 total.

12/13/2019

Draft for STD PCHD Project Areas' Review Only

Line No.
sna_54
sna_55
sna_56
sna_57
sna_58
sna_59
sna_60
sna_61
sna_62
sna_63
sna_64
sna_65
sna_66
sna_67
sna_68
sna_69
sna_70
sna_71
sna_72
sna_73

Descripton

12/13/2019

Complete 1 table per merchanism selected in SNA_Overall
Data Fields
Data Fields

Which mechanism does the following refer to?
Which of the following groups of clients does the following
testing data refer to?
How many tests were conducted?
Total tests conducted
All Males
Males, 15-24 years
Males, 25-44
Males, 45+
All Females
Females, 15-24 years
Females, 25-44
Females, 45+
Of those tests, how many were positive or reactive?
Total positive or reactive tests
All Males
Males, 15-24 years
Males, 25-44
Males, 45+
All Females
Females, 15-24
Females, 25-44
Females, 45+
Positivity

Data Fields

[Select from Drop down]
[Select from Dropdown]
Syphilis tests performed

GC tests performed

CT tests performed

Positive Syphilis tests

Positive GC tests

Positive CT tests

Among Syphilis tests performed

Among GC tests performed

Among CT tests performed

sna_74

Total tests

Enter Denominator

Enter Denominator

Enter Denominator

sna_75
sna_76
sna_77
sna_78
sna_79
sna_80
sna_81
sna_82

All Males
Males, 15-24 years
Males, 25-44
Males, 45+
All Females
Females, 15-24
Females, 25-44
Females, 45+
Treatment medication (if any purchased with STD PCHD safety
net assistance)
Total medication units purchased in reporting period. Please
write in units tracked by your program (e.g. "X# BIC injections"
or "Y# pills" or "Z# patient TX packs.")

Enter Denominator
Enter Denominator
Enter Denominator
Enter Denominator
Enter Denominator
Enter Denominator
Enter Denominator
Enter Denominator

Enter Denominator
Enter Denominator
Enter Denominator
Enter Denominator
Enter Denominator
Enter Denominator
Enter Denominator
Enter Denominator

Enter Denominator
Enter Denominator
Enter Denominator
Enter Denominator
Enter Denominator
Enter Denominator
Enter Denominator
Enter Denominator

Syphilis medication

GC medication

CT medication

sna_83

If you are unable to provide the above information on the tests performed, test results, or treatment purchases attributable to STD PCHD, please explain why not:

sna_84
(Optional) Please provide any other information you would like to add about the treatment or patient testing data that you provided on the safety net assistance in
the reporting period:
sna_85

Complete 1 table per merchanism selected in Admin_SNA_overall
Line No.
Descripton
Data Fields
Data Fields
sna_54 Which mechanism does the following refer to?
[Select from Drop down]
Which of the following groups of clients does the following
sna_55
[Select from Dropdown]
testing data refer to?
How many tests were conducted?
Syphilis tests performed
GC tests performed
sna_56 Total tests conducted
sna_57 All Males
sna_58 Males, 15-24 years
sna_59 Males, 25-44
sna_60 Males, 45+
sna_61 All Females
sna_62 Females, 15-24 years
sna_63 Females, 25-44
sna_64 Females, 45+
Of those tests, how many were positive or reactive?
Positive Syphilis tests
Positive GC tests
sna_65 Total positive or reactive tests
sna_66 All Males
sna_67 Males, 15-24 years
sna_68 Males, 25-44
sna_69 Males, 45+
sna_70 All Females
sna_71 Females, 15-24
sna_72 Females, 25-44
sna_73 Females, 45+
Positivity
Among Syphilis tests performed
Among GC tests performed
sna_74 Total tests
Enter Denominator
Enter Denominator
sna_75 All Males
Enter Denominator
Enter Denominator
sna_76 Males, 15-24 years
Enter Denominator
Enter Denominator
sna_77 Males, 25-44
Enter Denominator
Enter Denominator
sna_78 Males, 45+
Enter Denominator
Enter Denominator
sna_79 All Females
Enter Denominator
Enter Denominator
sna_80 Females, 15-24
Enter Denominator
Enter Denominator
sna_81 Females, 25-44
Enter Denominator
Enter Denominator
sna_82 Females, 45+
Enter Denominator
Enter Denominator
Treatment medication (if any purchased with STD PCHD safety
Syphilis medication
GC medication
net assistance)
Total medication units purchased in reporting period. Please
sna_83 write in units tracked by your program, e.g. "X# BIC injections"
or "Y# pills" or "Z# patient TX packs."

Data Fields

CT tests performed

Positive CT tests

Among CT tests performed
Enter Denominator
Enter Denominator
Enter Denominator
Enter Denominator
Enter Denominator
Enter Denominator
Enter Denominator
Enter Denominator
Enter Denominator
CT medication

If you are unable to provide the above information on the tests performed, test results, or treatment purchases attributable to STD PCHD, please explain why not:
sna_84
(Optional) Please provide any other information you would like to add about the treatment or patient testing data that you provided on the safety net assistance in
the reporting period:
sna_85

Complete 1 table per merchanism selected in Admin_SNA_overall
Line No.
Descripton
Data Fields
Data Fields
sna_54 Which mechanism does the following refer to?
[Select from Drop down]
Which of the following groups of clients does the following
sna_55
[Select from Dropdown]
testing data refer to?
How many tests were conducted?
Syphilis tests performed
GC tests performed
sna_56 Total tests conducted
sna_57 All Males
sna_58 Males, 15-24 years
sna_59 Males, 25-44
sna_60 Males, 45+
sna_61 All Females
sna_62 Females, 15-24 years
sna_63 Females, 25-44
sna_64 Females, 45+
Of those tests, how many were positive or reactive?
Positive Syphilis tests
Positive GC tests
sna_65 Total positive or reactive tests
sna_66 All Males
sna_67 Males, 15-24 years
sna_68 Males, 25-44
sna_69 Males, 45+
sna_70 All Females
sna_71 Females, 15-24
sna_72 Females, 25-44
sna_73 Females, 45+
Positivity
Among Syphilis tests performed
Among GC tests performed
sna_74 Total tests
Enter Denominator
Enter Denominator
sna_75 All Males
Enter Denominator
Enter Denominator
sna_76 Males, 15-24 years
Enter Denominator
Enter Denominator
sna_77 Males, 25-44
Enter Denominator
Enter Denominator
sna_78 Males, 45+
Enter Denominator
Enter Denominator
sna_79 All Females
Enter Denominator
Enter Denominator
sna_80 Females, 15-24
Enter Denominator
Enter Denominator
sna_81 Females, 25-44
Enter Denominator
Enter Denominator
sna_82 Females, 45+
Enter Denominator
Enter Denominator
Treatment medication (if any purchased with STD PCHD safety
Syphilis medication
GC medication
net assistance)
Total medication units purchased in reporting period. Please
sna_83 write in units tracked by your program, e.g. "X# BIC injections"
or "Y# pills" or "Z# patient TX packs."

Data Fields

CT tests performed

Positive CT tests

Among CT tests performed
Enter Denominator
Enter Denominator
Enter Denominator
Enter Denominator
Enter Denominator
Enter Denominator
Enter Denominator
Enter Denominator
Enter Denominator
CT medication

If you are unable to provide the above information on the tests performed, test results, or treatment purchases attributable to STD PCHD, please explain why not:
sna_84
(Optional) Please provide any other information you would like to add about the treatment or patient testing data that you provided on the safety net assistance in
the reporting period:
sna_85