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First name:
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Email Address:
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Retype Email Address:
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Phone number:
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Company Name:
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Business/Facility Address:
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City:
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Do you work in a:
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Physician Office Lab
Independent Reference Lab
National Lab
Acute Care Hospital
Other
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If you answered ‘other’ in the question above, please elaborate:
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Please fill in the specialty or specialties your facility services:
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Do you currently utilize a CLIA-waived rapid POC Chlamydia trachomatis/Neisseria gonorrhoeae (CT/NG) test in your clinic?
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Yes
No
Not applicable
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How many CT/NG tests do you run per month?
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Do you routinely screen asymptomatic patients who meet the CDC annual CT/NG screening recommendations?
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Yes
No
Not applicable
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If you do not routinely screen asymptomatic patients who meet the CDC annual CT/NG screening recommendations, why?
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What is your clinic’s prevalence rate for CT and NG?
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If you do not have a rapid CT/NG test in-house and use send out testing instead, what percentage of your patients are treated with antibiotic therapy presumptively, ie., before the send out CT/NG test results are returned?
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