Instructions for Completing the Minnesota Confidential STD Case Report
The following instructions should be used when filling out the Minnesota Confidential STD Case Report form. Health care providers should use this form to report lab confirmed cases of STDs as mandated by State law (Minnesota Rule 4605.7040). All case reports are classified as private under the Minnesota Government Data Practices Act. Laboratory reports do not substitute for physician case reports. Report only lab confirmed cases.
General Instructions
- Print in BOLD CAPITAL LETTERS clearly within the boxes with black ink.
- Do not touch the sides of the boxes. Fill in the circles or boxes completely or mark with an “X”.
- Do not use labels on the form for patient information.
Patient Information
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 box to the right of patient name.
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 box to the right of patient name.
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 and due date.
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:
SPECIMEN COLLECTION DATE
Print the date the specimen was collected in the numerical MMDDYYYY
format. For example, if specimen was collected on May 1, 2013, then print
“05-01-2013”
CT TREATMENT DATE
Print the date the patient was treated for the laboratory-confirmed chlamydial
infection in the numerical MMDDYYYY format. If the patient was not treated,
mark the box “NOT TREATED” and print an explanation in
the blank space below the question.
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. (See: CDC's STD Treatment Guidelines: Chlamydial Infections)
- Azithromycin (Zithromax®) 1 g orally in a single dose
- Doxycycline (Doxy®) 100 mg orally twice a day for 7 days
- Erythromycin base 500 mg orally four times a day for 7 days
- Erythromycin ethylsuccinate 800 mg orally four times a day for 7 days
- Ofloxacin (Floxin®) 300 mg orally twice a day for 7 days
- Levofloxacin (Levaquin®) 500 mg orally once daily for 7 days
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.
Complete the following fields if reporting a laboratory-confirmed gonorrhea case:
SPECIMEN COLLECTION DATE
Print the date the specimen was collected in the numerical MMDDYYYY
format. For example, if specimen was collected on May 1, 2013, then print
“05-01-2013”
GC TREATMENT DATE
Print the date the patient was treated for the laboratory-confirmed chlamydial
infection in the numerical MMDDYYYY format. If the patient was not treated,
mark the box “NOT TREATED” and print an explanation in
the blank space below the question.
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. (See: CDC's STD Treatment Guidelines: Gonococcal Infections)
- Ceftriaxone (Rocephin®) 250 mg in a single intramuscular dose PLUS Azithromycin (Zithromax®) 1 g orally in a single dose OR Doxycycline (Doxy®) 100 mg orally twice a day for 7 days
(Because of the high prevalence of tetracycline resistance among Gonococcal Isolate Surveillance Project isolates, particularly those with elevated minimum inhibitory concentrations to cefixime, the use of azithromycin as the second antimicrobial is preferred.) - Alternative regimens
If Ceftriaxone (Rocephin®) is not available:
Cefixime 400 mg in a single oral dose PLUS Azithromycin (Zithromax®) 1 g orally in a single dose OR Doxycycline (Doxy®) 100 mg orally twice a day for 7 days PLUS Test-of-cure in 1 week
(Because of the high prevalence of tetracycline resistance among Gonococcal Isolate Surveillance Project isolates, particularly those with elevated minimum inhibitory concentrations to cefixime, the use of azithromycin as the second antimicrobial is preferred.) -
If the patient has severe cephalosporin allergy:
Azithromycin (Zithromax®) 2 g in a single oral dose PLUS Test-of-cure in 1 week
Bottom of Form
- DIAGNOSED BY:
Print diagnosing physician’s last name, physician’s first name, clinic name, clinic address, phone number and fax 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.
Back of Form
- UNTREATED PARTNERS
If you would like MDH Partner Services assistance with private 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.
Complete the following fields if reporting a laboratory-confirmed syphilis case:
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, 2013, then print
“05-01-2013”
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.
Back of Form
- UNTREATED PARTNERS
If you would like MDH Partner Services assistance with private 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.
