Form Cdc 73.60 - C Control Strain Susceptibility Testing

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Gonococcal Isolate Surveillance Project
Regional Laboratory:
(3 letter code)
Form 3: Control Strain Susceptibility Testing
( SEE CODING INSTRUCTIONS ON BACK )
Form Approved OMB No. 0920-0307 Exp. 08 / 31 / 2016
MICs (μg/ml) to Antimicrobial Agents
Date tested
Pen
Tet
Gen
Cfx
Cro
Cip
Azi
Opt
ß-Lac
(mm/dd/yyyy)
A
F-18
___ / ___ / ______
1(P)
2(N)
A
F-28
___ / ___ / ______
1(P)
2(N)
A
SPL-4
___ / ___ / ______
1(P)
2(N)
A
P681E
___ / ___ / ______
1(P)
2(N)
A
CDC 10328
___ / ___ / ______
1(P)
2(N)
A
CDC 10329
___ / ___ / ______
1(P)
2(N)
A
SPJ-15
___ / ___ / ______
1(P)
2(N)
B
F-18
___ / ___ / ______
1(P)
2(N)
B
F-28
___ / ___ / ______
1(P)
2(N)
B
SPL-4
___ / ___ / ______
1(P)
2(N)
B
P681E
___ / ___ / ______
1(P)
2(N)
B
CDC 10328
___ / ___ / ______
1(P)
2(N)
B
CDC 10329
___ / ___ / ______
1(P)
2(N)
B
SPJ-15
___ / ___ / ______
1(P)
2(N)
C
F-18
___ / ___ / ______
1(P)
2(N)
C
F-28
___ / ___ / ______
1(P)
2(N)
C
SPL-4
___ / ___ / ______
1(P)
2(N)
C
P681E
___ / ___ / ______
1(P)
2(N)
C
CDC 10328
___ / ___ / ______
1(P)
2(N)
C
CDC 10329
___ / ___ / ______
1(P)
2(N)
C
SPJ-15
___ / ___ / ______
1(P)
2(N)
D
F-18
___ / ___ / ______
1(P)
2(N)
D
F-28
___ / ___ / ______
1(P)
2(N)
D
SPL-4
___ / ___ / ______
1(P)
2(N)
D
P681E
___ / ___ / ______
1(P)
2(N)
D
CDC 10328
___ / ___ / ______
1(P)
2(N)
D
CDC 10329
___ / ___ / ______
1(P)
2(N)
D
SPJ-15
___ / ___ / ______
1(P)
2(N)
Public reporting burden of this collection of information is estimated to average 12 minutes per run of 7 control strains (for a total monthly burden of 48 minutes per laboratory respondent), which includes the time required for transcribing the data from existing laboratory
records. 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, Project Clearance Officer, 1600 Clifton Road, MS E-11, Atlanta, GA 30333, ATTN: PRA (0920-0307). Do not send the completed form to this address.
CDC 73.60-C Rev 11-2015 (FRONT)
Gonococcal Isolate Surveillance Project / Form 3: Control Strain Susceptibility Testing
CS 260967A

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