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* 1. Name of Organization/Agency

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* 2. Contact Name

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* 3. Email

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* 4. Phone Number (Mobile or Office)

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* 5. Agency Website

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* 6. NCSD Member Type

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* 7. Type of Site

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* 8. What populations do you primarily serve (Check all that apply)

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* 9. Does your clinic serve pregnant women?

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* 10. Please provide an estimate on the number of patients you serve quarterly

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* 11. Please estimate the number of syphilis tests (any type) you conduct per month

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* 12. Please estimate the number of positive syphilis screenings your site identifies per month

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* 13. Does your facility have a CLIA Waiver?*

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* 14. Does your facility currently provide rapid plasma reagin (RPR) testing to your patients?*

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* 15. Do you run these RPRs within your facility or ship them out to a laboratory?

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* 16. Does your facility currently provide confirmatory testing for your patients?

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* 17. Does your clinic currently use these tests but need an additional supply?

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* 18. Does your clinic want to pilot these tests to consider for future use?

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* 19. If you were to receive this donation, what are your plans for long term sustainability?

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* 20. NCSD will be using the latest CDC-published surveillance data to look at STD morbidity in your state or county. Please describe local factors that we should consider in selecting your site for donation.

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* 21. Does your clinic provide Benzathine Penicillin as treatment for patients?

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* 22. If your clinic does not provide Benzathine Penicillin as treatment, what are your mechanisms for referrals?

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* 23. Does your clinic test for HIV at the same time of Syphilis screenings. If so, what type of HIV Test?

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* 24. How did you learn about the Syphilis Health CheckTM donation?

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* 25. Please describe the location of your storage site.*

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* 26. Does the storage facility have a loading dock?

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* 27. Please complete information for the person and place specifically responsible for receiving deliveries and storage.

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* 28. NCSD and Diagnostics Direct may want to publish tweets or Facebook posts about this donation. Would it be feasible to promote our partnership with your health department or organization?*

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* 29. What questions do you have for NCSD staff about the Syphilis Health CheckTM donation?

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