Disseminated gonococcal infection case report form (Version 1 March 2020)
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Disseminated gonococcal infection case report form (Version 1 March 2020)

Filetype[PDF-1.07 MB]


English
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  • Corporate Authors:
    National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (U.S.). Division of STD Prevention.
  • Description:
    CDC has received increasing reports of disseminated gonococcal infection (DGI), an uncommon, but severe, complication of untreated gonorrhea. CDC has created the DGI Case Report Form and REDCap Survey, which state and local health departments may use to collect the critical data elements we need to better understand and characterize DGI cases nationally. Follow the instructions below to voluntarily share existing and available epidemiological and clinical DGI case information with CDC. The submission of all data elements is not required. Keep a record of the REDCap ID with your local case ID so you can modify the form if any additions or changes are needed.

    DGI Case Report Form (Version 1 March 2020) Instructions

    Note: This form is for your records. To share information on a DGI case, the information in this form should be entered into the REDCap Survey or the completed form may be sent securely to CDC. The REDCap form includes skip patterns so some questions on the form may not be applicable to every case.

    DGI Form version 1 3.2020

    DGICaseReportingForm-508.pdf

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