340B STI Medication Administered Reporting
Complete a separate one report for each patient CDU 340B STI medication was administered to.

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Email *
County *
Location: If your location does not appear on this list and your clinic does not have it's own independent 340B designation email cdusupplies@wyo.gov  *
Medication #1 administered *
With the exception of pregnancy and allergy to doxycycline, azithromycin is no longer the preferred treatment for chlamydia. 
When patients are treated with non-standard treatment, CDU has to provide an explanation to CDC. 
If azithromycin was used instead of doxycycline, why was azithromycin used? 
If Azithromycin was not used type N/A.
*
Medication #1 lot number
Medication #1 expiration date - If month and year only, use last day of that month for day.
MM
/
DD
/
YYYY
Medication #1 NDC number
Medication #2 administered
With the exception of pregnancy and allergy to doxycycline, azithromycin is no longer the preferred treatment for chlamydia. 
When patients are treated with non-standard treatment, CDU has to provide an explanation to CDC. 
If azithromycin was used instead of doxycycline, why was azithromycin used? 
If Azithromycin was not used type N/A.
Medication #2 lot number
Medication #2 expiration date - If month and year only, use last day of that month for day.
MM
/
DD
/
YYYY
Medication #2 NDC number
Medication #3 administered
With the exception of pregnancy and allergy to doxycycline, azithromycin is no longer the preferred treatment for chlamydia. 
When patients are treated with non-standard treatment, CDU has to provide an explanation to CDC. 
If azithromycin was used instead of doxycycline, why was azithromycin used? 
If Azithromycin was not used type N/A.
Medication #3 lot number
Medication #3 expiration date -If month and year only, use last day of that month for day.
MM
/
DD
/
YYYY
Medication #3 NDC number
Medication #4 administered
With the exception of pregnancy and allergy to doxycycline, azithromycin is no longer the preferred treatment for chlamydia. 
When patients are treated with non-standard treatment, CDU has to provide an explanation to CDC. 
If azithromycin was used instead of doxycycline, why was azithromycin used? 
If Azithromycin was not used type N/A.
Medication #4 lot number
Medication #4 expiration date - If month and year only, use last day of that month for day.
MM
/
DD
/
YYYY
Medication #4 NDC number
Diagnosis/diagnoses (check all that apply) *
Required
Patient's insurance *
First name of the patient *
Last name of the patient *
Date of birth of the patient *
MM
/
DD
/
YYYY
Your Name *
Your contact phone number *
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