Att 3a - Clinic-based data elements

Form Approved

OMB No. 0920-0842

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	M=mandatory for transmission C=core	Question
State	STATE	N	2	M	What state is the patient being reported by?	Standard reporting state FIPS code, 99 = default
Survey county	COUNTY	N	3	M	Which survey county submitted this patient's data?	FIPS code, example: 075 (County of SF), 999 = default
Survey city	CITY	N	4	M	Which survey city submitted this patient's data?	FIPS code, example: 3290 (City of SF), default = 9999
Survey facility	FACILITY	N	2	M	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), 26=Broadway (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	M	Unique patient identification number assigned by state	Locally defined
Visit date	VISDATE	Date	10	M	What date was the patient's current visit?	mm/dd/yyyy
Event ID	EVENTID	C	18	M	Event identification number assigned by state	Locally defined
Sex	SEX	N	1	M	Are you male, female, or transgender?	1 = Male, 2 = Female, 3=Transgender M to F, 4=Transgender F to M, 5=Transgender unspecified, 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	Y	Haver you ever been diagnosed with GW?	0 = No, 1 = Yes, 9 = No answer/default
HIV history	HIVEVERTEST	N	1	Y	Haver you ever been tested for HIV?	0 = No, 1 = Yes, 9 = No answer/default
	HIVDATE	C	7	Y	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	Y	Was the patient tested for HIV at current visit?	0 = No, 1 = Yes, 9 = No/answer/default
	HIVRESULTTODAY	N	1	Y	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	Y	What type of HIV test was used at current visit?	1 = Conventional, 2 = Rapid, 3 = Other, 9 = No answer/default
Vaccine History	HPVVAXHX	N	1	Y	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	Y	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	Y	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	Y	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	Y	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	Trich sites only	Haver you ever been diagnosed with Trich?	0 = No, 1 = Yes, 9 = No answer/default
Patient symptoms	SXTRICH	N	1	Trich sites only	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	Trich sites only	Was there discharge on physical exam?	0 = No, 1 = Yes, 9 = No answer, not asked, refused, default
Care seeking behavior	DAYSTOCARE	N	3	N	How many days did you have your symptoms before you sought medical care?	0 = none/same day, 888 = Did not have symptoms, 999 = unknown/no answer/default
Patient symptoms	SXUROGENITAL	N	1	N	Do you have any urogenital symptoms today?	0 = No, 1 = Yes, 9 = No answer, not asked, refused, default
	SXRECTAL	N	1	N	Do you have any rectal symptoms today?	0 = No, 1 = Yes, 9 = No answer, not asked, refused, default
	SXPHARYNGEAL	N	1	N	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	N	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	N	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	N	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	N	Did you use a condom at last intercourse?	0 = No, 1 = Yes, 9 = No answer/default
Drug use	IVDU12	N	1	N	Have you injected drugs in past 12 months?	0 = No, 1 = Yes, 9 = No answer/default
	COCCRACK12	N	1	N	Have you used crack or cocaine in past 12 months?	0 = No, 1 = Yes, 9 = No answer/default
	METH12	N	1	N	Methamphetamines?	0 = No, 1 = Yes, 9 = No answer/default
	NITRATES12	N	1	N	Nitrates/poppers?	0 = No, 1 = Yes, 9 = No answer/default
	PERFDRUG12	N	1	N	Sexual performance enhancing drugs such as Viagra (sildenafil)?	0 = No, 1 = Yes, 9 = No answer/default/not applicable
	HEROIN12	N	1	N	Heroin?	0 = No, 1 = Yes, 9 = No answer/default
Exam findings	EXAM	N	1	N	Were there any abnormal findings during the physical exam?	0 = No, 1 = Yes, 9 = No answer, not asked, refused, default
	PEULCER	N	1	N	Was there an ulcer or blister on physical exam?	0 = No, 1 = Yes, 9 = No answer, not asked, refused, default
	PERASH	N	1	N	Was there a rash on physical exam?	0 = No, 1 = Yes, 9 = No answer, not asked, refused, default
	PECMTADTEND	N	1	N	Was there cervical motion or adnexal tenderness on physical exam?	0 = No, 1 = Yes, 9 = No answer, not asked, refused, default
	PECERVICITIS	N	1	N	Was there cervicitis on physical exam?	0 = No, 1 = Yes, 9 = No answer, not asked, refused, default
	PEPHARYNX	N	1	N	Was there pharyngitis on physical exam?	0 = No, 1 = Yes, 9 = No answer, not asked, refused, default
	PEPROCTITIS	N	1	N	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	N	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	N	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	N	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	N	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	N	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	N	Have you been in jail or prison in the past 12 months?	0 = No, 1 = Yes, 9 = No answer/default
	INCARCPART12	N	1	N	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	N	Haver you ever been diagnosed with GC?	0 = No, 1 = Yes, 9 = No answer/default
	CTEVER	N	4	N	Haver you ever been diagnosed with CT?	0 = No, 1 = Yes, 9 = No answer/default
	SYPHEVER	N	2	N	Haver you ever been diagnosed with syphilis?	0 = No, 1 = Yes, 9 = No answer/default
STD contact	STDCONT	N	1	N	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