Sexually Transmitted Diseases  >  Program Guidelines  >  Surveillance and Data Management

Program Operations Guidelines for STD Prevention
Surveillance and Data Management

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Appendix S-D

EXAMPLE: ANNUAL CLINICAL LABORATORY SURVEY CALENDAR YEAR ---

(Use space below to record name or address changes)
_____________________________________
_____________________________________
_____________________________________

CLIA Number: ___________________

Laboratory Director ________________ Phone: ________________

Professional Degree(s): _________________________

Contact Person: ________________________ Title: ____________

Phone: _______________________ FAX: ____________________

1. Which of the following categories best describes your laboratory? (Check one.)

___ Private Hospital                     ___ Free-Standing Private

___ Public Health                        ___ Non-Profit Hospital

___ Blood Bank                           ___ Custody Facility

___ VA/Military Hospital              ___ Community Clinic

___ Student Health Services        ___ Physicians Office/Group Practice

___ HMO                                    ___ Other (specify) ______________

2. If no STD (syphilis, chlamydia, gonorrhea, chancroid, herpes, HIV, etc.) or TB tests were performed on site, please check the appropriate line below and return the survey in the envelope provided.

___ No STD or TB tests were processed through or performed by this facility this year.

___ This facility is a Draw Station for: ________________________

 

3. Are any STD specimens sent to laboratories outside the state or county for testing? ____ Yes ____ No

If "Yes," please indicate the approximate percentage _________ and laboratories used:

Lab Name _________________________ CLIA # _______________ State ___

Lab Name _________________________ CLIA # _______________ State ___

4. Are any STD specimens for testing received from clinical providers located outside the state or county? __ Yes ___ No

If "Yes," indicate the approximate percentage (check one).

____0% ____5% ____10% ____25% ____50% ____75% ____90% ____100%

 

Indicate by circling "No" or "Yes" those tests currently performed by your laboratory. Record the number of tests and the number positive for CALENDAR YEAR——. Please be as precise as possible.

	Performed? (circle)	# Performed	# Positive	Number of Days Test is Performed*
5. SYPHILIS:  RPR (Qualitative)	No   Yes
RPR (Quantitative)	No   Yes
VDRL (Qualitative)	No   Yes
VDRL (Quantitative)	No   Yes
FTA-ABS	No   Yes
TPPA	No   Yes
VDRL on CSF	No   Yes
Darkfield	No   Yes
DFA-TP	No   Yes
Other:	No   Yes
* Please indicate the number of days per week test is performed. Are "rough" non-treponemal tests diluted to rule out prozone reactions? ____ Yes ____ No What is policy for performing confirmatory (treponemal) tests: ____ Routinely, on all reactive non-treponemal findings ____ By Request Only

   

 

	Performed? (circle)	# Performed	# Positive	Manufacturer of Test (if appropriate)
6. GONORRHEA: Urethral Gram Stain*	No   Yes
GC Culture	No   Yes
DNA Probe (Single)	No   Yes
DNA Probe (Combo)	No   Yes
LCR	No   Yes
Other:	No   Yes
* Please do not include gram stains done to identify culture isolates Does the laboratory perform MICs on positive gonorrhea cultures?____ Yes ____ No Does laboratory perform beta-lactamase testing on GC isolates? ____ Yes ____ No

 

 

	Performed? (circle)	# Performed	# Positive	Manufacturer of Test (if appropriate)
7. CHLAMYDIA: Culture	No   Yes
DFA	No   Yes
EIA	No   Yes
DNA Probe (Single)	No   Yes
DNA Probe (Combo)	No   Yes
LCR	No   Yes
PCR	No   Yes
TMA	No   Yes
Other:	No   Yes
If applicable: Is verification assay performed on positive EIA findings? ____ Yes ____ No Is verification assay performed on positive DNA probe findings? ____ Yes ____ No Are DNA probe findings in the "gray zone" repeated? ____ Yes ____ No If yes, define the gray zone used: ______________________ Does laboratory perform C. trachomatis serologic testing? ____ Yes ____ No

8. HEPATITIS B:

Hep. B Surface Antigen ____ No____ Yes____ # performed ______ # positive ______

Test Manufacturer ________________

 

9. HUMAN IMMUNODEFICIENCY VIRUS (HIV):
EIA	No   Yes
Western Blot	No   Yes
IFA	No   Yes
PCR	No   Yes
Other:	No   Yes

 

10. HERPES SIMPLEX VIRUS (HSV):
Culture	No   Yes
DFA	No   Yes
Other:	No   Yes

11. HUMAN PAPILLOMA VIRUS INFECTION (HPV):

Test Type ___________  No Yes    ____________     ____________     ___________

	Performed? (circle)	# Performed	# Positive
12. CHANCROID (Haemophilus ducreyi): Gram Stain	No   Yes
Culture	No   Yes
13. TUBERCULOSIS (TB): Culture	No   Yes
Smear	No   Yes

14. Does this laboratory use a reference lab to confirm any positive STD tests? __ Yes  __ No

If " Yes," please indicate for which tests and the laboratories used.

Test:

Laboratory:

City:

15. Does your laboratory have a computerized data system? ____ Yes ____ No

 

If " Yes," please answer the following questions:

Is it a commercially available software program? ___ Yes ___ No

If " Yes," specify ______________________________________

Information Collected: _______ Billing ______ Provider ______ Patient _____ Test Results

Is lab able to generate periodic reports of negative and positive results for individual providers?

___ Yes ___ No

16. How does your laboratory report test results? By mail _____ By FAX ____ Electronically ____ Other ____

17. How often does your laboratory report? Daily ____ Weekly ____ Monthly ____

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