Instructions for Completing the Minnesota Confidential STD Case Report
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Instructions for Completing the Minnesota Confidential STD Case Report (PDF: 20KB/6 pages)
The following instructions should be used when filling out the Minnesota Confidential STD Case Report form. The form should be used by health care providers to report laboratory-confirmed cases of chlamydia, gonorrhea, syphilis, and chancroid to the Minnesota Department of Health (MDH).
General Instructions
- Print in CAPITAL LETTERS clearly within the boxes with a black or blue pen.
- Do not touch the sides of the boxes. Fill in the circles completely or mark with an “X”.
- Do not use labels on the form for patient information.
- Do not submit photocopies of the form.
Front of Form
PATIENT’S LAST NAME, FIRST NAME, M.I.
Print patient’s last name, first name, and middle initials in capital
letters.
COUNTRY OF BIRTH
Mark the patient’s country of birth. “United States”
refers to the continental United States, Hawaii, or Alaska. “Other”
refers to any other country, including a U.S. dependency or possession
(e.g., Puerto Rico). If “Other” is marked, print the name
of the country in capital letters on the line provided.
ADDRESS, APT/UNIT NO, CITY/TOWN, STATE
Print patient’s street address of residence at the time of specimen
collection. If the patient is homeless or the address is unknown, leave
the boxes blank and mark the appropriate circle above the ADDRESS box.
ZIP CODE
Enter the patient’s five-digit zip code of residence at the time
of specimen collection. If the patient is homeless or the address is unknown,
leave the boxes blank and mark the appropriate circle above the ADDRESS
box.
DATE OF BIRTH
Print the patient’s date of birth in the numerical MM/DD/YYYY format.
For example, if the patient was born on January 15, 1975, print “01
/ 15 / 1975”.
MEDICAL RECORD NO.
Print the patient’s medical record number.
AREA CODE, PHONE NUMBER
Print the patient’s area code and phone number.
GENDER
Mark the patient’s gender. Mark only one.
PREGNANT
If the patient is female, mark her pregnancy status at the time of specimen
collection and if known write in the number of weeks in the pregnancy.
ETHNICITY
Mark the patient’s ethnicity as reported by the patient. Mark only
one.
Based on the federal 1997 OMB Directive 15, the definition of the first
category is:
“Hispanic or Latino” -- A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.
RACE
Mark one or more racial designations as reported by the patient. If “Other”
is marked, print the patient’s self-reported race in capital letters
on the line provided.
Based on the federal 1997 OMB Directive 15, the definitions of the categories
are:
“American Indian or Alaska Native” -- A person having origins in any of the original peoples of North and South America (including Central America), and who maintains a tribal affiliation or community attachment.
“Asian” – A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippines Islands, Thailand, and Vietnam.
“Black or African American” – A person having origins in any of the black racial groups of Africa.
“Native Hawaiian or Other Pacific Islander” – A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
“White” – A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.
GENDER OF SEX PARTNERS
Mark the gender(s) of the patient’s sex partner(s). Mark all that
apply. Include all sexual partners who had contact with the patient during
the following time periods:
Chlamydia – 60 days preceding onset of symptoms or diagnosis of
chlamydia in patient
Gonorrhea – 60 days preceding onset of symptoms or diagnosis of
gonorrhea in patient
Syphilis –12 months preceding diagnosis of primary, secondary, or
early latent syphilis
Complete the following fields if reporting a laboratory-confirmed chlamydia case…
CT DIAGNOSIS
Mark the laboratory-confirmed chlamydia diagnosis. Mark only one.
SPECIMEN SOURCE
Mark the source of the specimen used for chlamydia testing. Mark all that
apply. If “Other” is marked, print the site in capital letters
on the line provided.
CT TREATMENT
Mark the treatment(s) administered to the patient for the laboratory-confirmed
chlamydia diagnosis. Mark all that apply. If “Other” is marked,
print the name of the medication and the dosage on the line provided.
Azithromycin (Zithromax®)
Doxycycline (Doxy®)
Erythromycin base
Erythromycin ethylsuccinate
Ofloxacin (Floxin®)
Levofloxacin (Levaquin®)
Note: If the patient is a laboratory-confirmed gonorrhea case that received dual therapy without a laboratory-confirmed chlamydia diagnosis, DO NOT mark the presumptive chlamydia treatment in this section. Instead, report the presumptive treatment within the GONORRHEA section under “CO-TREATMENT for Presumptive Chlamydia infection”.
SPECIMEN COLLECTION DATE
Print the date the specimen was collected in the numerical MM/DD/YYYY
format. For example, if specimen was collected on May 1, 2010, then print
“05 / 01 / 2010”
CT TREATMENT DATE
Print the date the patient was treated for the laboratory-confirmed chlamydial
infection in the numerical MM/DD/YYYY format. If the patient was not treated,
mark the circle “NOT TREATED” and print an explanation in
the blank space below the question.
Complete the following fields if reporting a laboratory-confirmed gonorrhea case…
GC DIAGNOSIS
Mark the laboratory-confirmed gonorrhea diagnosis. Mark only one.
SPECIMEN SOURCE
Mark the source of the specimen used for gonorrhea testing. Mark all that
apply. If “Other” is marked, print the site in capital letters
on the line provided.
GC TREATMENT
Mark the treatment(s) administered to the patient for the laboratory-confirmed
gonorrhea diagnosis. Mark all that apply. If “Other” is marked,
enter the name of the medication and the dosage on the line provided.
Cefixime (Suprax®)
Ceftriaxone (Rocephin®)
Cefpodoxime (Vantin®)
Spectinomycin
CO-TREATMENT for Presumptive Chlamydial infection
If the laboratory-confirmed gonorrhea case was presumptively treated for
chlamydia (dual therapy), mark the presumptive treatment administered.
Azithromyin (Zithromax®)
Doxycline (Doxy®)
SPECIMEN COLLECTION DATE
Print the date the specimen was collected in the numerical MM/DD/YYYY
format. For example, if specimen was collected on May 1, 2010, then print
“05 / 01 / 2010”
GC TREATMENT DATE
Print the date the patient was treated for the laboratory-confirmed gonorrhea
infection in the numerical MM/DD/YYYY format. If the patient was not treated,
mark the circle “NOT TREATED” and print an explanation in
the blank space below the question.
SYPHILIS DIAGNOSIS
Mark the laboratory-confirmed syphilis diagnosis. Mark only one.
SYPHILIS TREATMENT
Mark the treatment(s) administered to the patient for the laboratory-confirmed
syphilis diagnosis. Mark all that apply. If “Other” is marked,
enter the name of the medication and the dosage on the line provided.
SPECIMEN COLLECTION DATE
Print the date the specimen was collected in the numerical MM/DD/YYYY
format. For example, if specimen was collected on May 1, 2010, then print
“05 / 01 / 2010”
TREATMENT DATE
Print the date the patient was treated for the laboratory-confirmed syphilis
infection in the numerical MM/DD/YYYY format. If the patient was not treated,
mark the circle “NOT TREATED” and print an explanation in
the blank space below the question.
TEST TYPE / RESULTS
Mark the circle corresponding to the type of test(s) performed and print
the result (e.g., titer) on the line provided.
LAB
Print the name of the laboratory that performed the diagnostic test on
the line provided.
Complete the following field if reporting a chancroid case…
CHANCROID DIAGNOSIS
Mark the circle if reporting a case of chancroid. The case must be a laboratory-confirmed
case of chancroid (i.e., isolation of H. ducreyi from a clinical specimen)
OR a clinically compatible case with tests to exclude syphilis and herpes.
CHANCROID TREATMENT
Print the treatment(s) administered to the patient for the chancroid diagnosis.
Bottom of Form
DIAGNOSED BY:
Print diagnosing physician’s last name, physician’s first
name, clinic name, and clinic address and phone number.
REPORTED BY:
Print the last name, first name of the person completing the case report
form, as well as the clinic name and phone number of the reporting facility.
MDH USE ONLY:
Please do not mark or enter anything in this box.
Back of Form
PARTNER SERVICES DATA FOR UNTREATED PARTNERS
If you would like MDH assistance with partner notification, enter the
name(s) and complete locating information of UNTREATED PARTNERS within
the last 60 days for gonorrhea and chlamydia and within the last 90 days
for syphilis.
Please indicate if you would like to receive:
Mark materials you would like to receive. Mark all that apply.