SSuN Variable List
STD Clinic Based Surveillance
Data Elements
Attachment 3a
Contact Information:
Deborah Dowell, MD
National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention
DSTDP/ESB
Centers for Disease Control and Prevention
1600 Clifton Road NE, MS E02
Atlanta, GA 30333.
Phone: (404) 639-8334
Fax: (404) 639-8610
Email: gdo7@cdc.gov
07/21/2009
Form Approved
OMB No. 0920-09XX
Expiration Date XX/XX/20XX
STD Clinic Based Surveillance
Data Elements
Public reporting burden of this collection of information is estimated to average 2 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 persons 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 (0920-09XX)
Domain |
Variable name |
Type |
Length |
S=standardized C=core |
Question |
Response coding |
State |
STATE |
N |
2 |
C |
What state is the patient being reported by? |
Standard reporting state FIPS code, 99 = default |
Survey county |
COUNTY |
N |
3 |
C |
Which survey county submitted this patient's data? |
FIPS code, example: 075 (County of SF), 999 = default |
Survey city |
CITY |
N |
4 |
C |
Which survey city submitted this patient's data? |
FIPS code, example: 3290 (City of SF), default = 9999 |
Survey facility |
FACILITY |
N |
2 |
C |
What survey facility submitted this patient's data? |
10=Jefferson County (AL), 15=Druid (Balt), 16=Eastern (Balt), 20=Englewood (Chic), 21=Howard Brown (Chic), 22=Lakeview (Chic), 23=Roseland (Chic), 24=South Austin (Chic), 25=West Town (Chic), 30=Denver (CO), 40=Hartford (CT), 41=New Haven (CT), 50=Antelope Valley (Los Ang), 51= Central (Los Ang), 52=Curtis Tucker (Los Ang), 53=Hollywood-Wilshire (Los Ang), 54=Monrovia (Los Ang), 55=North Hollywood (Los Ang), 56=Pomona (Los Ang), 57=Ruth Temple (Los Ang), 58=Simms Mann (Los Ang), 59=South (Los Ang), 60=Torrance (Los Ang), 61=Whittier (Los Ang), 65=Delgado (Louisiana), 70=Bushwick (NYC), 71=Central Harlem (NYC), 72=Chelsea (NYC), 73=Corona (NYC), 74=East Harlem (NYC), 75=Fort Greene (NYC), 76=Jamaica (NYC), 77=Morrisania (NYC), 78=Richmond (NYC), 79=Riverside (NYC), 80=Health Clinic #1 (Philly), 81=Health Clinic #5 (Philly), 85=SF City Clinic (SF), 90=Richmond City (VA), 91=Henrico East (VA), 92=Chesterfield (VA), 93=Henrico West (VA) 95=Seattle-King County (WA) |
Patient ID |
PATIENTID |
C |
16 |
C |
Unique patient identification number assigned by state |
Locally defined |
Visit date |
VISDATE |
Date |
10 |
C |
What date was the patient's current visit? |
mm/dd/yyyy |
Event ID |
EVENTID |
C |
18 |
C |
Event identification number assigned by state |
Locally defined |
Sex |
SEX |
N |
1 |
C |
Are you male, female, or transgender? |
1 = Male, 2 = Female, 3 = Transgender unspecified, 4 = Transgender (M to F), 5 = Transgender (F to M), 9 = No answer/default |
County of Residence |
COUNTYRES |
N |
3 |
C |
What county does the patient reside in? |
FIPS code, example: 075 (County of SF), 999 = default/unknown |
Age |
AGE |
N |
2 |
C |
How old are you? |
Age in years, 99 = No answer/default |
Hispanic |
HISP |
N |
1 |
C |
Are you of Hispanic ethnicity? |
0 = No, 1 = Yes, 9 = No answer/default |
Race |
AIAN |
N |
1 |
C |
Are you American Indian or Alaska Native? |
0 = No, 1 = Yes, 9 = No answer/default |
|
ASIAN |
N |
1 |
C |
Are you Asian? |
0 = No, 1 = Yes, 9 = No answer/default |
|
PIH |
N |
1 |
C |
Are you Pacific Islander or Hawaiian? |
0 = No, 1 = Yes, 9 = No answer/default |
|
BLACK |
N |
1 |
C |
Are you Black? |
0 = No, 1 = Yes, 9 = No answer/default |
|
WHITE |
N |
1 |
C |
Are you White? |
0 = No, 1 = Yes, 9 = No answer/default |
|
OTHERRACE |
N |
1 |
C |
Are you another race not listed above? |
0 = No, 1 = Yes, 9 = No answer/default |
Sex of sex partners |
MENSEX3 |
N |
4 |
C |
How many male sex partners have you had in the last 3 months? |
#; 9999 = No answer, refused, default |
|
FEMSEX3 |
N |
4 |
C |
How many female sex partners have you had in the last 3 months? |
#; 9999 = No answer, refused, default |
|
SEXOR3 |
N |
1 |
C |
Have you had sex with men, women, or both over the past 3 months? |
1 = Men, 2 = Women, 3 = Both, 4 = None, 9 = No answer/default |
|
NUMSEX3 |
N |
4 |
C |
How many sex partners have you had in the past 3 months? |
#; 9999 = No answer, refused, default |
|
SEXUALITY |
N |
1 |
C |
Do you consider yourself gay (homosexual), straight (heterosexual), or bisexual? |
1 = gay/homosexual, 2=straight/heterosexual, 3=bisexual, 9 = No answer/default |
Pregnancy status |
PREGNANT |
N |
1 |
C |
Are you pregnant today? |
0 = No, 1 = Yes, 8 = Don't know, 9 = No answer/default/male |
HIV history |
HIVRESULTLAST |
N |
1 |
C |
What was your last HIV test result? |
0 = Negative, 1 = Positive, 2 = Indeterminate, 9 = Unknown/didn't receive results/not applicable/default |
Visit type |
VISITTYPE |
N |
2 |
C |
Type of current clinic visit |
0 = HIV testing only, 1 = clinician, 2 = express/fast track, 3 = result only, 4 = treatment only, 5 = follow-up, 6 = DIS referral (not clinician visit), 7 = STI vaccine only, 8 = other, 9 = No answer/unknown |
Patient symptoms |
SYMPPT |
N |
1 |
C |
Does the patient have any STD symptoms today? |
0 = No, 1 = Yes, 9 = No answer, not asked, refused, default |
GW history |
GWEVER |
N |
5 |
S |
Have you ever been diagnosed with GW? |
0 = No, 1 = Yes, 9 = No/answer/default |
HIV history |
HIVEVERTEST |
N |
1 |
S |
Have you ever been tested for HIV? |
0 = No, 1 = Yes, 9 = No/answer/default |
|
HIVDATE |
C |
7 |
S |
When were you last tested for HIV? |
mm/yyyy, put 99 in mm if pt doesn't know month, blank = unknown/default |
|
HIVTESTTODAY |
N |
1 |
S |
Was the patient tested for HIV at current visit? |
0 = No, 1 = Yes, 9 = No/answer/default |
|
HIVRESULTTODAY |
N |
1 |
S |
What was the result of the HIV test at the current visit? |
0 = Negative, 1 = Positive/preliminary positive, 2 = Indeterminant, 9 = Unknown |
|
HIVTYPETODAY |
N |
1 |
S |
What type of HIV test was used at current visit? |
1 = Conventional, 2 = Rapid, 3 = Other |
Vaccine History |
HPVVAXHX |
N |
1 |
S |
Have you ever been vaccinated for HPV/ human papillomavirus, cervical cancer? |
0 = No/never, 1 = Yes partially, 2 = Fully, 8 = Unsure/don't know, 9 = No answer/default |
|
HPVVAXADMIN |
N |
1 |
S |
Was the patient given a dose of HPV vaccine at this visit? |
0 = No, 1 = Quad dose #1, 2 = Quad dose #2, 3 = Quad dose #3, 4 = Quad dose #undefined, 5 = Bivalent dose #1, 6 = Bivalent dose #2, 7 = Bivalent dose #3, 8 = Bivalent dose #undefined, 9 = No answer/default |
Physical exam findings |
PEWARTS |
N |
1 |
S |
Was there a genital wart on physical exam? |
0 = No, 1 = Yes, 9 = No answer, not asked, refused, default |
GW treatment provider |
GWTXPROV |
N |
2 |
S |
Were any of these treatments administered by the provider for genital warts? |
0 = No treatment given by provider, 1= Excision, 2 = Cryotherapy, 3 = Podophyllin, 4 = Trichloroacetic or bicholoroacetic acid (TCA or BCA), 5 = Intralesional interferon, 6 = Laser surgery, 8 = Other, 9 = No answer/default, 11 = Cryotherapy & Podophyllin, 12 = Cryotherapy & Trichloroacetic acid |
GW treatment patient |
GWTXPT |
N |
1 |
S |
Were any of these treatments prescribed or given to the patient for self-treatment of genital warts? |
0 = No prescription or medications given to patient for self-treatment, 3 = Podofilox (Condylox), 4 = Green tea extracts, 7 = Imiquimod (Aldara), 8 = Other, 9 = Unknown/default |
STD history |
TRICHEVER |
N |
4 |
S |
Haver you ever been diagnosed with Trich? |
0 = No, 1 = Yes, 9 = No/answer/default |
Patient symptoms |
SXTRICH |
N |
1 |
S |
Do you have either vaginal discharge, odor or itching? |
0 = No, 1 = Yes, 9 = No answer, not asked, refused, default |
Physical exam findings |
PEDISCHARGE |
N |
1 |
S |
Was there discharge on physical exam? |
0 = No, 1 = Yes, 9 = No answer, not asked, refused, default |
Care seeking behavior |
DAYSTOCARE |
N |
3 |
S |
How many days did you have your symptoms before you sought medical care? |
0 = none/same day, 888 = Did not have symptoms, 999 = unknown/noanswer/default |
Patient symptoms |
SXUROGENITAL |
N |
1 |
S |
Do you have any urogenital symptoms today? |
0 = No, 1 = Yes, 9 = No answer, not asked, refused, default |
|
SXRECTAL |
N |
1 |
S |
Do you have any rectal symptoms today? |
0 = No, 1 = Yes, 9 = No answer, not asked, refused, default |
|
SXPHARYNGEAL |
N |
1 |
S |
Do you have any pharyngeal symptoms (e.g., a sore throat) today? |
0 = No, 1 = Yes, 9 = No answer, not asked, refused, default |
Anonymous sex partners |
ANONSEX12 |
N |
1 |
S |
Have you had sex with anyone in the past 12 months that you would not be able to contact again? |
0 = No, 1 = Yes, 9 = No answer/default |
Internet |
INTERNET12 |
N |
1 |
S |
Have you met sex partners through the Internet in the past 12 months? |
0 = No, 1 = Yes, 9 = No answer/default |
Commercial sex |
EXCHANGESEX12 |
N |
1 |
S |
Have you given or received drugs or money for sex in the past 12 months? |
0 = No, 1 = Yes, 9 = No answer/default |
Condom use |
CONDOM |
N |
1 |
S |
Did you use a condom at last intercourse? |
0 = No, 1 = Yes, 9 = No answer/default |
Drug use |
IVDU12 |
N |
1 |
S |
Have you injected drugs in past 12 months? |
0 = No, 1 = Yes, 9 = No answer/default |
|
COCCRACK12 |
N |
1 |
S |
Have you used crack or cocaine in past 12 months? |
0 = No, 1 = Yes, 9 = No answer/default |
|
METH12 |
N |
1 |
S |
Methamphetamines? |
0 = No, 1 = Yes, 9 = No answer/default |
|
NITRATES12 |
N |
1 |
S |
Nitrates/poppers? |
0 = No, 1 = Yes, 9 = No answer/default |
|
PERFDRUG12 |
N |
1 |
S |
Sexual performance enhancing drugs such as Viagra (sildenafil)? |
0 = No, 1 = Yes, 9 = No answer/default/not applicable |
|
HEROIN12 |
N |
1 |
S |
Heroin? |
0 = No, 1 = Yes, 9 = No answer/default |
Exam findings |
EXAM |
N |
1 |
S |
Were there any abnormal findings during the physical exam? |
0 = No, 1 = Yes, 9 = No answer, not asked, refused, default |
|
PEULCER |
N |
1 |
S |
Was there an ulcer or blister on physical exam? |
0 = No, 1 = Yes, 9 = No answer, not asked, refused, default |
|
PERASH |
N |
1 |
S |
Was there a rash on physical exam? |
0 = No, 1 = Yes, 9 = No answer, not asked, refused, default |
|
PECMTADTEND |
N |
1 |
S |
Was there cervical motion or adnexal tenderness on physical exam? |
0 = No, 1 = Yes, 9 = No answer, not asked, refused, default |
|
PECERVICITIS |
N |
1 |
S |
Was there cervicitis on physical exam? |
0 = No, 1 = Yes, 9 = No answer, not asked, refused, default |
|
PEPHARYNX |
N |
1 |
S |
Was there pharyngitis on physical exam? |
0 = No, 1 = Yes, 9 = No answer, not asked, refused, default |
|
PEPROCTITIS |
N |
1 |
S |
Was there proctitis on physical exam? |
0 = No, 1 = Yes, 9 = No answer, not asked, refused, default |
Census tract of patient address |
TRACT |
C |
11 |
S |
What census tract does the patient reside in? |
U.S. Census tract, code first 5 digits if only state/county known, code first 2 digits if only state known, leave blank if all unknown |
Accuracy of patient address |
ACCURACY |
N |
2 |
S |
How accurate is the geocoded data on this patient? |
1=Close (based on direct street segment, parcel, or longitude/latitude match), 2=Approximate (modification of address required to match 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) |
Education |
EDUCATION |
N |
1 |
S |
What is the highest level of education that you have completed? |
1 = less than HS grad/GED, 2=HS grad/GED, 3= Some college, 4= 4 year college or more, 9 = unknown/no answer/default |
Employment status |
STUDENT |
N |
1 |
S |
Are you a student at this time? |
0 = No, not a student, 1 = Yes, full-time student, 2= Yes, part-time student, 9 = No answer/default |
|
EMPLOY |
N |
1 |
S |
What is your employment status at this time? |
1= Employed, 2 = Self-employed, 3 = Out of work for more than 1 year, 4 = Out of work for less than 1 year, 5 = Homemaker, 6 = Retired, 7 = Unable to work, 9 = No answer/default |
Incarceration |
INCARC12 |
N |
1 |
S |
Have you been in jail or prison in the past 12 months? |
0 = No, 1 = Yes, 9 = No answer/default |
|
INCARCPART12 |
N |
1 |
S |
Have you had sex in the past 12 months with a partner who has been in jail or prison recently? |
0 = No, 1 = Yes, 9 = No answer/default |
STD history |
GCEVER |
N |
1 |
S |
Haver you ever been diagnosed with GC? |
0 = No, 1 = Yes, 9 = No/answer/default |
|
CTEVER |
N |
4 |
S |
Haver you ever been diagnosed with CT? |
0 = No, 1 = Yes, 9 = No/answer/default |
|
SYPHEVER |
N |
2 |
S |
Haver you ever been diagnosed with syphilis? |
0 = No, 1 = Yes, 9 = No/answer/default |
STD contact |
STDCONT |
N |
1 |
S |
Are you seeking care today because you have a sex partner with an STD? |
0 = No, 1 = Yes, 9 = No answer, not asked, refused, default |
File Type | application/msword |
File Title | Attachment 3 |
Author | svp8 |
Last Modified By | shari steinberg |
File Modified | 2009-08-26 |
File Created | 2009-08-25 |