Form 0920-25-0177 Gay City Data Collection

Form Approved

OMB No. 0920-1357

Expiration Date: XX\XX\XXXX

The Greater Access and Impact with NAT (GAIN) Study: Improving HIV Diagnosis, Linkage to Care, and Prevention Services with HIV Point-of-Care Nucleic Acid Tests (NATs)

Attachment 4i

Seattle Clinic Data Collection

Public reporting burden of this collection of information is estimated to average 60 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 D-74, Atlanta, Georgia 30333; Attn: OMB-PRA (0920-1357)

Seattle Clinic Data Variables List

patient_emr

visit_date

study_aim

dob

patient_name

patient_phone

end_date

SPECIMEN..

LAST.NAME

FIRST.NAME

MIDDLE.NAME

GENDER

DOB

AGE

SPECIMEN.TYPE

SPECIMEN.SOURCE

TEST.CODE.NAME

RESULT.CODE.NAME

RESULT

TEST.DATE

COLLECT.DATE

ACCT

PROVIDER

EXT.MRN