Form 0920-1072 Gonorrhea Patient Interview section 1

Attachment 8
Interview Templates

Enhanced STD Surveillance Network (SSuN)
Previous OMB# 0920-1072

SSuN Patient Interview(s) [Version 10.1]
(1) GC Patient Interview
(2) Neuro/Ocular Syphilis Initial Screening Interview
(3) Neuro/Ocular Syphilis Follow-up Interview

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Version 10.1 (July 2018)

Form a pproved:
OMB No. 0920-1072
Expi ra tion date: 06/30/2018

(1)
Gonorrhea Patient Interview
Suggested Introductory Script – Patient Verbal (Informal) Consent

(All Information in this introductory section for LOCAL USE ONLY; no hard-copies sent to CDC)
HELLO, My name is________ and I am calling for the ________________health department about your recent
doctor’s appointment with _______________ (mention name & date of patient’s visit to reporting
provider/facility).
[Interviewer must assure that they are speaking to the appropriate person by confirming date of birth, date of
doctor visit, etc. Local DIS protocols should be followed with respect to initial patient contact and
confirmation of patient identity]
We are gathering information about people recently diagnosed with (gonorrhea/chlamydia) in
___________________(name of city/state) to help make sure that the best care is available and to help prevent
the spread of (gonorrhea/chlamydia) in the future. This project is being conducted by the ___________(health
department) with funding from and in collaboration with the U.S. Centers for Disease Control and Prevention.
Your name was randomly chosen from among all of the people recently diagnosed and reported to the health
department. I would like to ask some questions about your experience at your recent doctor’s visit and about
your recent health behaviors related to your diagnosis. These questions should only take about 10 minutes and
any information you give me will be kept strictly confidential.
The information you are being asked to provide is authorized to be collected under Sections 301 304, 306 and
308(d)of The Public Health Service Act (42 USC 241). Providing this information is voluntary. CDC will use this
information in the STD Surveillance Network, to collect critical clinical, demographic and behavioral information
through enhanced surveillance among people diagnosed with gonorrhea or early syphilis with ocular/neurologic
involvement in order to provide a valid and reliable data source for evaluating progress toward national public
health goals, to evaluate effectiveness of CDC published treatment recommendations, and ascertain behavioral
characteristics among these populations that may influence STD risk. This information will be shared with
participating state/local health departments with whom CDC has entered into an agreement to assist with
carrying out this study.
You do not have to answer any question you do not want to, and you can end the interview at any time. Your
name will not be shared with anyone and all of the information we gather will be combined with others so that
no one individual can ever be identified. Is this a good time for you and would you be willing to help with this
important project?
[If patient agrees, go to Module 1, Question 14]
[If patient refuses]We’re sorry you don’t want to participate but thank you very much for your time anyway!
[If patient agrees but states that it is not a good time:]
When would be a good time to call you back? __________________________
Is this the best telephone number to use for you? _______________________________________
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[If patient states that they wish to call the interviewer back, provide your name HD affiliation and phone
number; ask the patient to confirm approximately when they will call]
Thank you, I look forward to hearing from you on _____________ (day) at ___________(time).
Public Burden Statement
The public reporting burden for this information collection is estimated to be 10 minutes. This burden estimate
includes time for reviewing instructions, researching existing data sources, gathering and maintaining the
needed data, and completing and submitting the information. Send comments regarding the accuracy of this
burden estimate and any suggestions for reducing the burden to: U.S. Office of Personnel Management, Federal
Investigative Services, Attn: OMB Number (0920-1072), 1900 E Street NW, Washington, DC 20415-7900. You are
not required to respond to this collection of information unless a valid OMB control number is displayed.
Interviewer Use Only: Was verbal consent obtained for interview?

Y

N

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Process Information
1

Interviewer:______________________________ID#________

2

PatientID:___________________________________________

3

EventID:_____________________________________________
Contact Attempts:

4

Date___/___/______;

5 Outcome__________________________________________

Notes:______________________________________________________________________
6

Date___/___/______;

7 Outcome__________________________________________

Notes:______________________________________________________________________
8

Date___/___/______;

9 Outcome__________________________________________

Notes:______________________________________________________________________
10

Date___/___/______;

11 Outcome__________________________________________

Notes:______________________________________________________________________
12

Interview/Disposition Date ___/___/______

13

Phase 3 Investigation Disposition Code:

00- Investigation complete: patient contacted, interview completed

01- Investigation complete: patient contacted, partial interview completed

10- Investigation not complete: Phase 3 investigation pending

11- Investigation not complete: patient contacted, refused interview

12- Investigation not complete: patient contacted, language barrier.

22- Investigation not complete: patient did not respond to any/all interview contact
attempts

33- Investigation not complete: patient contact not initiated because patient
resident in correctional, mental health or substance abuse facility.

44- Investigation not complete: patient contact not initiated because patient is
active military on foreign deployment.

55- Investigation not complete for other reason: Specify __________________
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Module 1 - Demographics
Interviewer Read: These first few questions are about you and where you live.
14 What is your age?
____ ____

[code in years]

888- Refused

15 Do you consider yourself to be…?
Please read choices:[Check only one]

1- Male

2- Female

3- Transgender (M to F)

4- Transgender (F to M)

Do not read:

5- Transgender (refused to specify)

8- Refused

16 Do you consider yourself to be Hispanic or Latino/a?

1- Hispanic (Go to Question 16.1)

2- Non-Hispanic (Skip to Question 17)

3- Unknown (Skip to Question 17)

4- Refused (Skip to Question 17)

16.1 Do you consider yourself to be…?

1- Mexican, Mexican Am., Chicano/a, Latino/a

2- Puerto Rican

3- Cuban

4- Other Hispanic Origin (SPECIFY) 16.2 ______________________________________

5- Unknown

9- Refused
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17 Which one or more of the following would you say best describes your race?
Please read all choices (except Other): [Check all that apply]
17

White

Y

N

U

R

18

Black or African American

Y

N

U

R

19

American Indian or Alaska Native

Y

N

U

R (If Yes, Go To 19.1)

19.1 Tribal Affiliation (SPECIFY) ______________________________
20

Y

Asian
20.1

1 - Asian Indian (India)

4 - Korean

21

2 - Japanese

Y

U

R (If Yes, Go To 20.1)

3 - Chinese

5 - Filipina/o
6 - Other Asian

Native Hawaiian or Other Pacific Islander
21.1

N

N

1 - Native Hawaiian
2 - Guamanian/Chamorro

9 - Refused

U

R (If Yes, Go To 21.1)

3 - Samoan

4 - Other Pacific Island (SPECIFY) 21.2__________________________________

9 - Refused
22

Other [DO NOT READ, probe and specify if no other response is appropriate]________________
______________________________________________________________________________

Do not read:
23
23.1

Refused all race information

Y

N

Where were you born?

In the U.S.

Specify State _______________________________

Outside of the U.S.

23.2 Specify Country ______________________________________

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Module 2 – Healthcare Experience
Interviewer Read: These questions are about your recent doctor’s visit (when you were tested for
[gonorrhea/chlamydia]) and about your access to medical care in general. [Interviewer should mention specific
provider, if known]
24 Do you have any kind of health care coverage, including health insurance, prepaid plans such as HMOs, or
government plans such as Medicare, Indian Health Services, the V.A. or Military?

1- Yes [GO TO 25]

2- No

3- Don‘t know / Not sure [SKIP TO 26]

4- Refused [SKIP TO 26]

[SKIP TO 26]

25 What kind of healthcare insurance do you have?

1- Private healthcare insurance provided by my employer

2- Private healthcare insurance I pay for myself

3- Public healthcare insurance like Medicaid, Medicare, or [insert state-specific
Medicaid-like plan name]

4- Active/retired military or dependent plan like the V.A. or military

5- Bureau of Indian Affairs/Indian Health Service/Urban Indian Health Board

7- Other

8- Don‘t know / Not sure

9- Refused

Specify 25a ___________________________________

26 Do you have one person you think of as your personal doctor or health care provider?
If ‘No’, ask: ‘Is there more than one, or is there no person who you think of as your personal doctor or
health care provider?’ (Note: if respondent identifies a facility or provider setting rather than individual,
then code response as 2)

1- Yes, only one

2- More than one (or a facility)

3- No

4- Don‘t know / Not sure

5- Refused
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27 Was there a time in the past 12 months when you needed to see a doctor but could not because of cost?

1- Yes

2- No

3- Don‘t know / Not sure

4- Refused

28 When you went to see _______________ [interviewer: insert reporting provider, clinic or facility name from
case report] when you were diagnosed with (gonorrhea/chlamydia), did you need to pay anything out-ofpocket, like a co-pay, deductible or cash payment, at the time of your visit? (Note: this question is meant to
determine if respondent had to pay any amount of money to the provider at the time of visit; do not include
billed amounts or deferred or waived charges.)

1- Yes

2- No

3- Don‘t know /Not sure / Don’t remember

4- Refused

28.1 Before you went to see _______________ [interviewer: insert reporting provider, clinic or facility name
from case report], did you have any unusual discharge or oozing from your (penis/vagina)? (Note: this question
is meant to determine if respondent had genital symptoms before their health care visit.)

1- Yes

2- No

3- Don‘t know /Not sure / Don’t remember

4- Refused

28.2 Before you went to see _______________ [interviewer: insert reporting provider, clinic or facility name
from case report], did you notice any unexplained sores or bumps on your (penis/vagina)? (Note: this question is
meant to determine if respondent had genital symptoms before their health care visit.)

1- Yes

2- No

3- Don‘t know /Not sure / Don’t remember

4- Refused

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28.3 Before you went to see _______________ [interviewer: insert reporting provider, clinic or facility name
from case report], did you have any pain or burning when you urinated? (Note: this question is meant to
determine if respondent had genital symptoms before their health care visit.)

1- Yes

2- No

3- Don‘t know /Not sure / Don’t remember

4- Refused

29 Did you go to the doctor that time because you were having symptoms or pains you thought might be from
an STD?

1- Yes [GO TO 30]

2- No [SKIP TO 31]

3- Don‘t know / Not sure / Don’t remember [SKIP TO 31]

4- Refused [SKIP TO 31]

30 How long did you have these symptoms or pains before you were able to see the doctor? (Note:
probe as needed to elicit most specific response.)

1- 1 Day

2- 2 to 6 days

3- 1 to 2 weeks

4- More than 2 weeks

5- Don‘t know / Not sure / Don’t remember

6- Refused

31 Before you went to the doctor that time, did any of your sex partners tell you that you might have been
exposed to an STD?

1- Yes

2- No

3- Don‘t know / Not sure / Don’t remember

4- Refused

Are any of the following reasons why you went to ___________ [Interviewer: insert provider name] for that
medical visit instead of going somewhere else?
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[Read all responses]
Did you go…
32. Because this is your usual/regular doctor.

Y

N

33. Because you could get seen for free.

Y

N

34. Because they take your insurance.

Y

N

35. Because you felt more comfortable about your privacy there.

Y

N

36. Because you could get seen right away.

Y

N

37. Because you wanted to see an expert specializing in STDs.

Y

N

38. Because this doctor is close to your house and easy to get to.

Y

N

39. Because you were embarrassed and didn’t want to go to your regular doctor.

Y

N

40. Because I didn’t want the insurance papers/info sent to my home/parents.

Y

N

41. Any other Reason?
Y

N

(specify) 42. ______________________________________

43.
Refused all reasons
44 During that visit, did the doctor, nurse or anyone else talk to you about the importance of getting your sex
partners examined and tested for STDs?

1- Yes

2- No

3- Don‘t remember / Not sure

4- Refused

45 In the time since you found out that you had (gonorrhea/chlamydia), have you told any of your sex partners
that they may need to be tested or treated for (gonorrhea/chlamydia)?

1- Yes

2- No

3- Don‘t Know / Not sure

4- Refused

Interviewer Read: “In some places, doctors, nurses or the health department may help you to get your sex
partners treated for (gonorrhea/chlamydia) by providing extra medications or prescriptions for your partners.”

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46 Did a doctor, nurse or someone at the health department offer to give you medications or a prescription for
you to give to any of your sex partner(s)?

1- Yes [GO TO 47]

2- No [SKIP TO QUESTION 52]

3- Don‘t know / Not sure [SKIP TO QUESTION 52]

4- Refused [SKIP TO QUESTION 52]

47 Who was it that offered you medications or prescriptions for your partners? Was it someone from
your doctor’s office, someone from the health department or someone else?

1- My doctor’s office [GO TO 48]

2- The health department [GO TO 48]

3- Someone else [GO TO 48]

4- Don‘t know / Not sure [GO TO 48]

5- Refused [SKIP TO QUESTION 52]

48 Did you actually get the medications or prescriptions for your sex partners?

1- Yes [GO TO 49]

2- No [SKIP TO QUESTION 52]

3- Don‘t know / Don’t remember/ Not sure [SKIP TO QUESTION 52]

4- Refused [SKIP TO QUESTION 52]

49 Did you get extra medicine to give to your partner? Or did you get prescriptions that your partners
needed to have filled at a pharmacy?

1- I got additional medications [GO TO 50]

2- I got prescription(s) [GO TO 50]

3- Don‘t know / Not sure [SKIP TO QUESTION 52]

50 Did you give the medications or prescriptions to at least one of your sex partners?

1- Yes, I gave them to at least one of my partner(s)

2- No, I did not give them to any of my partner(s)

9- Refused
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52 Did you get tested for HIV at the doctor’s visit when you were tested for (gonorrhea/chlamydia)?

1- Yes, I got an HIV test at that visit [GO TO 53]

2- No, I did not get an HIV test [SKIP TO 54]

3- Don‘t know / Not sure [SKIP TO 54]

4- Refused [SKIP TO 54]

53 What was the result of your HIV test?

1- My HIV test was Positive [GO TO 57]

2- My HIV test was Negative [SKIP TO 58.1]

3- Don‘t know / Not sure / Didn’t get my results [SKIP TO 58.1]

4- Refused [SKIP TO 58.1]

54 Have you ever been tested for HIV?

1- Yes [GO TO 55]

2- No [SKIP TO 58.1]

3- Don‘t know / Not sure [SKIP TO 58.1]

4- Refused [SKIP TO 58.1]

55 When was your last HIV test? Just month and year is ok?
Month ________ [use probes and elicit best guess if patient is not sure]
Year __________ [use probes and elicit best guess if patient is not sure]
[If patient refuses to guess, enter ‘..’ for month and ‘….’ for year.]
56 What was the result of that HIV test?

1- My HIV test was Positive [GO TO 57]

2- My HIV test was Negative [SKIP TO 58.1]

3- Don‘t know /Not sure/Didn’t get results [SKIP TO 58.1]

4- Refused [SKIP TO 58.1]

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57 When was your most recent visit to a doctor, nurse or other health care worker specifically for HIV
medical care? Just the month and year is ok.
Month ________ [use probes and elicit best guess if patient is not sure]
Year __________ [use probes and elicit best guess if patient is not sure]
(Note: Enter ‘99’ for month and ‘9999’ for year if patient is still unable to remember; enter ‘88’
and ‘8888’ if patient explicitly refuses to provide date, enter ‘77’ and ‘7777’ if patient has not
had first HIV primary care visit yet. DIS should provide referral to HIV care if indicated.)
58 Are you taking antiretroviral medicines to treat your HIV infection?

1- Yes [FEMALES GO TO 59, MALES SKIP TO 60]

2- No [FEMALES GO TO 59, MALES SKIP TO 60]

3- I don‘t know / I am not sure [FEMALES GO TO 59, MALES SKIP TO 60]

4- Refused [FEMALES GO TO 59, MALES SKIP TO 60]

58.1 When you were diagnosed with gonorrhea, did your health care provider discuss medications to help you
prevent getting HIV? This is often called PrEP, or pre-exposure prophylaxis.

1- Yes [GO TO 58.2]

2- No [FEMALES GO TO 59, MALES SKIP TO 60]

3- Don‘t know / Not sure [FEMALES GO TO 59, MALES SKIP TO 60]

4- Refused [FEMALES GO TO 59, MALES SKIP TO 60]

58.2 Did your health care provider prescribe medications to help you prevent getting HIV?

1- Yes [GO TO 58.3]

2- No [FEMALES GO TO 59, MALES SKIP TO 60]

3- Don‘t know / Not sure [FEMALES GO TO 59, MALES SKIP TO 60]

4- Refused [FEMALES GO TO 59, MALES SKIP TO 60]

58.3 Did you fill a prescription or get medications to help you prevent getting HIV?

1- Yes [GO TO 58.4]

2- No [FEMALES GO TO 59, MALES SKIP TO 60]

3- Don‘t know / Not sure [FEMALES GO TO 59, MALES SKIP TO 60]

4- Refused [FEMALES GO TO 59, MALES SKIP TO 60]
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58.4 Are you currently taking medications to help you prevent getting HIV?

1- Yes [FEMALES GO TO 59, MALES SKIP TO 60]

2- No [FEMALES GO TO 59, MALES SKIP TO 60]

3- Don‘t know / Not sure [FEMALES GO TO 59, MALES SKIP TO 60]

4- Refused [FEMALES GO TO 59, MALES SKIP TO 60]

59 Were you pregnant at the time you were told that you had (gonorrhea/chlamydia)?

1- Yes, I was pregnant at that time

2- No , I was not pregnant at that time

3- Don‘t know / Not sure

4- Refused

Module 3 – Behaviors
Interviewer Read: “The following questions are about your sexual health and behaviors. Not all of these
questions may apply to you but we have to ask them for everyone – please let me know if a specific question
does not apply and we can move on to the next one. Remember, everything you tell me is strictly confidential
and will not be shared except when combined anonymously with the information from all of the other people
we talk with.”

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60 During the past 12 months, have you had sex with only males, only females, or with both males and females?

1- Men only

2- Women only

3- Both men and women

4- Unknown

9- Refused

61 Do you consider yourself to be…?
[Read all choices]

1- Heterosexual/Straight

2- Gay/Lesbian/Homosexual

3- Bisexual

4- Other

[Do not read]

9- Refused

62 Thinking back to the 3 months before you were diagnosed with (gonorrhea/chlamydia), how many MEN did
you have sex with during that time? _________ [Probe: “It’s ok to guess if you don’t know exactly.”]

9999- Refused

63 Thinking back to the 3 months before you were diagnosed with (gonorrhea/chlamydia), how many WOMEN
did you have sex with during that time? _________ [Probe: “It’s ok to guess if you don’t know exactly.”]

9999- Refused

Based on responses to number of sex partners, EPT questions and to patient’s knowledge of their partner’s
treatment status, DIS may facilitate EPT following local protocols at the conclusion of the interview. Please
document EPT or other partner services provided to the patient in question 74 at the end of the interview.
Read: Regardless of your previous answers about getting extra medications or prescriptions…
If patient reports only a single sex partner:
63.1 To the best of your knowledge, was your sex partner treated?

1- Yes, definitely

2- Yes, probably

3- Don‘t know / Not sure

4- No, probably not

5- Refused
If patient reports multiple sex partners:
63.2 To the best of your knowledge, would you say that all of your sex partners were definitely treated, at
least one of your partners was definitely treated, or that none were treated?

1- All definitely treated

2- At least one definitely treated

3- At least one probably treated

4- Not sure

5- Probably none treated

6- Refused
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64 In the past 12 months, have you given drugs or money in exchange for sex, or received drugs or money in
exchange for sex? By sex we mean any vaginal, oral, or anal sex.

1- Yes

2- No

3- Don‘t know / Not sure

4- Refused

64.1 In the past year, how often have you used prescription pain medications (regardless of whether they were
prescribed by a physician for a medical condition)?

1- Never

2- Once or Twice

3- Monthly

4- Weekly

5- Daily or Almost Daily

9- Refused

64.2 In the past year, have you used any injection drugs such as heroin, cocaine or meth?

1- Yes [GO TO 64.3]

2- No [SKIP TO 65]

3- Don’t Know/Can’t Remember [SKIP TO 65]

4- Refused [SKIP TO 65]

64.3. In the past year, did you inject…(read all, check all that apply)?

1- Heroin

2- Cocaine

3- Crack

4- Oxycodone/morphine/Fentanyl/Carfentanil/some other opioid

5- Other not listed

6- Don’t Know/Can’t Remember

9- Refused
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Interviewer Read: “The next few questions are about the most recent time you had sex and about the person
you had sex with. By sex we mean any vaginal, oral or anal sex.”

65 When was the last time you had sex with someone?

1- In the last week

2- More than 1 week ago but within the last month

3- More than 1 month ago but within the last 2 months

4- More than 2 months ago

5- Don’t know / Not sure

9- Refused

66 Thinking back to that last time you had sex, was the person you had sex with…?
Read all, select appropriate response:

1- Male

2- Female

3- M-F Transgender

4- F-M Transgender

Do not read:

5- Unknown

9- Refused

67 Thinking back to the last person you had sex with, how old do you think that person is? If you don’t know for
sure, it’s OK to make your best guess. [Note: probe with age groups, older, younger, etc. Attempt to elicit single
number if at all possible.]
_________ (years)

888- Unknown/Couldn’t Guess

999- Refused

68 Would you say that person is Hispanic/Latino/a? If you don’t know for sure, it’s OK to make your best guess.

1- Yes, Hispanic

2- No, Not Hispanic
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8- I don’t know/Can’t Guess

9- Refused

69 Thinking back to the last person you had sex with, what race would you say that person is? If you don’t know
for sure, it’s OK to make your best guess.
Read all, select best response:

1- White

2- Black

3- AI/AN

4- ASIAN

5- NH/OPI

Do not read:

8- I don’t know/I can’t guess

9- Refused

70 Thinking back to the last person you had sex with, do you know if that person HIV positive?

1- I know this person is HIV+

2- I know this person in HIV-

3- I don’t know this person’s HIV status

4- Refused

71 Thinking back to the last person you had sex with; do you think you will have sex with this person again?

1 Yes

2 No

3 Don‘t know / Not sure

4 Refused

72 Thinking back to the last person you had sex with, about how far away do you think that person lives from
you – how long do you think it would it take to get to where they live from your home? If you don’t know for
sure, it’s OK to make your best guess. Which of these answers fits best?

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[Note: interviewer should clarify the question if the respondent expresses confusion, and elicit a response with
probes if needed. If asked the reason why this is important, interviewer can explain that this information will
help in promoting neighborhood and community prevention efforts]
Read list:

0- They live with me

1- Less than 5 minutes away

2- 5 to 15 minutes away

3- 16 - 30 minutes away

4- 30 or more minutes but less than one hour away

5- > one hour away

6- They live in another state

7- They live in another country (outside of the United States)

Do not read:

8- I Don’t know/I’m not Sure

9- Refused

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SSuN Interview Conclusion Script
If no additional partner management activity:
That’s all the questions we have – thank you for your time and for your help with this important project. Do you
have any questions for me before we end? Remember, everything we talked about today is strictly confidential.
If referring to partner management or eliciting partners: proceed with local partner services protocol.

Optional Partner Services / Other Referrals Provided (if applicable)
73 Did interviewer/DIS provide EPT/PDPT to patient?

1 Yes

2 No

74 Number of partners EPT provided for ________
75 Did interviewer/DIS provide any other partner services to patient (DIS referral, partner notification,
risk reduction counseling, HIV testing referral, etc.)?

1 Yes

2 No

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SSuN Syphilis Initial Interview [Version 1]

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(2) For Patients with Syphilis
Identified Through Routine HD
Investigation Who Reported
Ocular/Neuro Symptoms Only

Form a pproved:
OMB No. 0920-1072
Expi ra tion date: 06/30/2018

Public Burden Statement
The public reporting burden for this information collection is estimated to be 10 minutes. This burden estimate
includes time for reviewing instructions, researching existing data sources, gathering and maintaining the
needed data, and completing and submitting the information. Send comments regarding the accuracy of this
burden estimate and any suggestions for reducing the burden to: U.S. Office of Personnel Management, Federal
Investigative Services, Attn: OMB Number (0920-1072), 1900 E Street NW, Washington, DC 20415-7900. You are
not required to respond to this collection of information unless a valid OMB control number is displayed.

Process Information
A

Interviewer:______________________________ID#________

B

PatientID:___________________________________________

C

EventID:____________________________________________

D

Interview/Disposition Date ___/___/______

1
Has a doctor or other medical person recently told you that you had neurosyphilis, or syphilis affecting
your brain, eyes, or ears?

Y (GO to #2)
N (SKIP to #3)
U (SKIP to #3)
2

Where was this diagnosis made?
Please read choices:[Check only one]

3

1- STD Clinic

2- HIV Care Facility

3- Eye Clinic

4- Emergency Room

5- Primary Care Clinic

6- Other________________________________________________

9- Unknown

Have you experienced a change in hearing in the past 60 days?
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Y
4

Have you experienced hearing loss in the past 60 days?

Y

3

N

Have you experienced stroke-like symptoms in the past 60 days?

Y

8

N

Have you experienced an altered mental status in the past 60 days?

Y

7

N

Have you experienced headaches in the past 60 days?

Y

6

N

Have you experienced ringing or buzzing in your ears (tinnitus) in the past 60 days?

Y

5

N

Have you experienced a change in hearing in the past 60 days?

Y

4

N

N

Have you experienced other neurological symptoms in the past 60 days?

Y

N (Go to #9)

Other symptoms?______________________________________________
9

Have you experienced eye pain in the past 60 days?

Y

10

Have you experienced blurry vision in the past 60 days?

Y

11

N

Have you experienced any flashing lights in the past 60 days?

Y

14

N

Have you experienced vision changes in the past 60 days?

Y

13

N

Have you experienced red eye in the past 60 days?

Y

12

N

N

Have you experienced any floaters in the past 60 days?
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Y
15

Have you experienced vision loss in the past 60 days?

Y

16

N

N

Have you experienced any other ocular symptoms in the past 60 days?

Y

N (GO to #17)

Other symptoms?______________________________________________
17

As part of your care for syphilis, did you receive a spinal tap or lumbar puncture?

Y (GO to #18)

18

N (END)

U (END)

If you received a spinal tap or lumbar puncture what was the Month/Day/Year?

MM_________ DD_________YYYY_________

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SSuN Syphilis Follow-up Interview [Version 1]

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(3) For Patients Who Reported
Ocular/Neuro Symptoms Only
and Who Were Previously
Interviewed

Form a pproved:
OMB No. 0920-1072
Expi ra tion date: 06/30/2018

Public Burden Statement
The public reporting burden for this information collection is estimated to be 5 minutes. This burden estimate
includes time for reviewing instructions, researching existing data sources, gathering and maintaining the
needed data, and completing and submitting the information. Send comments regarding the accuracy of this
burden estimate and any suggestions for reducing the burden to: U.S. Office of Personnel Management, Federal
Investigative Services, Attn: OMB Number (0920-1072), 1900 E Street NW, Washington, DC 20415-7900. You are
not required to respond to this collection of information unless a valid OMB control number is displayed.

Process Information
A

Interviewer:______________________________ID#________

B

PatientID:___________________________________________

C

EventID:____________________________________________

D

Interview/Disposition Date ___/___/______

E

What types of providers did the patient encounter for these symptoms? [Select all that apply]

1

A- HIV care provider

B- Primary care provider

C- Ophthalmology

D- A & B above

E- B & C above

F- A & C above

G- A, B & C above

Has your change in hearing resolved?
Please read choices:[Check only one]

1- Never experienced this symptom

2- Yes, 100 % resolved
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2

3- Yes, mostly resolved,

4- Yes, but only resolved somewhat,

5- No, symptom has persisted or worsened

Has your hearing loss resolved?
Please read choices:[Check only one]

3

1- Never experienced this symptom

2- Yes, 100 % resolved

3- Yes, mostly resolved,

4- Yes, but only resolved somewhat,

5- No, symptom has persisted or worsened

Has the buzzing or ringing in your ears (tinnitus) resolved?
Please read choices:[Check only one]

4

1- Never experienced this symptom

2- Yes, 100 % resolved

3- Yes, mostly resolved,

4- Yes, but only resolved somewhat,

5- No, symptom has persisted or worsened

Have your headaches resolved?
Please read choices:[Check only one]

5

1- Never experienced this symptom

2- Yes, 100 % resolved

3- Yes, mostly resolved,

4- Yes, but only resolved somewhat,

5- No, symptom has persisted or worsened

Has your altered mental status resolved?
Please read choices:[Check only one]

1- Never experienced this symptom
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6

2- Yes, 100 % resolved

3- Yes, mostly resolved,

4- Yes, but only resolved somewhat,

5- No, symptom has persisted or worsened

Has your eye pain resolved?
Please read choices:[Check only one]

7

1- Never experienced this symptom

2- Yes, 100 % resolved

3- Yes, mostly resolved,

4- Yes, but only resolved somewhat,

5- No, symptom has persisted or worsened

Has your red eye resolved?
Please read choices:[Check only one]

8

1- Never experienced this symptom

2- Yes, 100 % resolved

3- Yes, mostly resolved,

4- Yes, but only resolved somewhat,

5- No, symptom has persisted or worsened

Has your blurry vision resolved?
Please read choices:[Check only one]

9

1- Never experienced this symptom

2- Yes, 100 % resolved

3- Yes, mostly resolved,

4- Yes, but only resolved somewhat,

5- No, symptom has persisted or worsened

Have your vision changes resolved?
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Please read choices:[Check only one]

10

1- Never experienced this symptom

2- Yes, 100 % resolved

3- Yes, mostly resolved,

4- Yes, but only resolved somewhat,

5- No, symptom has persisted or worsened

Has your vision loss resolved?
Please read choices:[Check only one]

11

1- Never experienced this symptom

2- Yes, 100 % resolved

3- Yes, mostly resolved,

4- Yes, but only resolved somewhat,

5- No, symptom has persisted or worsened

Have your floaters resolved?
Please read choices:[Check only one]

12

1- Never experienced this symptom

2- Yes, 100 % resolved

3- Yes, mostly resolved,

4- Yes, but only resolved somewhat,

5- No, symptom has persisted or worsened

Have the flashing lights resolved?
Please read choices:[Check only one]

1- Never experienced this symptom

2- Yes, 100 % resolved

3- Yes, mostly resolved,

4- Yes, but only resolved somewhat,
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13

5- No, symptom has persisted or worsened

Were there any other symptoms not listed that have since resolved?
If Yes, what symptoms ________________________________________________
Please read choices:[Check only one]

14

1- Never experienced this symptom

2- Yes, 100 % resolved

3- Yes, mostly resolved,

4- Yes, but only resolved somewhat,

5- No, symptom has persisted or worsened

Were there any other symptoms not listed that have since resolved (2)?
If Yes, what symptoms (2) ________________________________________________
Please read choices:[Check only one]

15

1- Never experienced this symptom

2- Yes, 100 % resolved

3- Yes, mostly resolved,

4- Yes, but only resolved somewhat,

5- No, symptom has persisted or worsened

Did you experience a change in hearing following treatment?

Yes

16

Did you experience a loss in hearing following treatment?

Yes

17

No

Did you experience headaches following treatment?

Yes

18

No

No

Did you experience any stroke-like symptoms following treatment?

Yes

No
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19

Did you experience an altered mental status following treatment?

Yes

20

Did you experience a ringing or buzzing in ears (tinnitus) following treatment?

Yes

21

No

Did you experience any flashing lights following treatment?

Yes

28

No

Did you experience any vision loss following treatment?

Yes

27

No

Did you experience any floaters following treatment?

Yes

26

No

Did you experience any vision changes following treatment?

Yes

25

No

Did you experience any blurry vision following treatment?

Yes

24

No

Did you experience any red eye following treatment?

Yes

23

No

Did you experience any eye pain following treatment?

Yes

22

No

No

Did you experience any other symptoms following treatment?

Yes, __________________________________________

No

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