Form Approved
OMB Control No.: 0920-1310
Expiration date: XX/XX/XXXX
AR Lab Network Alert and Monthly Data Report Form for Neisseria gonorrhoeae (SHARP)
Unique Etest AR Lab Network Specimen ID |
Submitter facility state, territory, or jurisdiction |
Patient Age |
Patient's Gender |
Travel History |
Explain (If yes for Travel History) |
Reason for Requesting Test |
Explain? (If 'Other' for previous question) |
If requesting due to suspected treatment failure, what treatment was administered/dispensed at the initial evaluation? |
Specimen Source |
Date of specimen collection |
Date the test was performed by your lab |
Ceftriaxone (CRO) MIC |
Alert confirmatory testing performed? |
CRO confirmation MIC |
Cefixime (CFM) MIC |
Alert confirmatory testing performed? |
CFM confirmation MIC |
Azithromycin (AZM) MIC |
Ciprofloxacin (CIP) MIC |
Lab comments |
Is this isolate being sequenced? |
What is this isolate's GC WGS ID? |
Has this isolate been uploaded to NCBI? |
Date uploaded to NCBI SRA |
BioSample number |
NCBI sample accession number |
Public reporting burden of this collection of information is estimated to average 6 minutes 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 H21-8, Atlanta, Georgia 30333; ATTN: PRA 0920-1310
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Swaray, Masiray (CDC/DDID/NCEZID/DHQP) (CTR) |
| File Modified | 0000-00-00 |
| File Created | 2024-10-28 |