Supplemental Materials - Surveillance Forms
12
State of California—Health and Human Services Agency California Department of Public Health Street Address Patient’s Name (Last) (First) (M.I.) REPORT OF VERIFIED CASE OF TUBERCULOSIS (ZIP CODE) State Code Year Reported (YYYY) Locally Assigned Identification Number REPORT OF VERIFIED CASE OF TUBERCULOSIS 1. Date Reported 3. Case Numbers State Case Number City/County Case Number Linking State Case Number Linking State Case Number 2. Date Submitted Month Day Year Month Day Year Reason: 4. Reporting Address for Case Counting City Within City Limits (select one) Yes No 8. Date of Birth Month Day Year County 9. Sex at Birth (select one) Male Female 11. Race (select one or more) American Indian or Alaska Native White Black or African American Asian: Specify Native Hawaiian or Other Pacific Islander: Specify ZIP CODE 10. Ethnicity (select one) Not Hispanic or Latino Hispanic or Latino 5. Count Status (select one) Countable TB Case Noncountable TB Case Count as a TB case in your jurisdiction Verified Case: Counted by another U.S. area (state) Verified Case: Recurrent TB within 12 months after completion of therapy Verified Case: TB treatment initiated in another country Specify 6. Date Counted Month Day Year 7. Previous Diagnosis of TB Disease (select one) If YES, enter year of previous TB disease diagnosis: Yes No 12. Country of Birth “U.S.-born” (or born abroad to a parent who was a U.S. citizen) (select one) Yes No Country of birth: Specify 13. Month-Year Arrived in U.S. Year Month 14. Pediatric TB Patients (<15 years old) 16. Site of TB Disease (select all that apply) 15. Status at TB Diagnosis (select one) Month Day Year Country of Birth for Primary Guardian(s): Specify Patient lived outside U.S. for >2 months? (select one) If DEAD, enter date of death: If DEAD, was death related to TB disease? (select one) Bone and/or Joint Genitourinary Meningeal Peritoneal Other: Enter anatomic code(s) (see list): Site not stated Pulmonary Pleural Lymphatic: Cervical Lymphatic: Intrathoracic Lymphatic: Axillary Lymphatic: Other Lymphatic: Unknown Laryngeal Yes No Unknown Yes No Unknown Alive Dead 1 2 3 { Guardian 1 Guardian 2 If YES, list countries, specify: Public reporting burden of this collection of information is estimated to average 35 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and main- taining the data needed and completing and reviewing the collection of information. 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 D-74, Atlanta, CA 30333, ATTN: PRA (0920-0026). Do not send the completed form to this address. Information contained on this form which would permit identification of any individual has been collected with a guarantee that it will be held in strict confidence, will be used only for surveillance purposes, and will not be disclosed or released without the consent of the individual in accordance with Section 308(d) of the Public Health Service Act (42 U.S.C. 242m). CDPH 8620A (1/3) Rev. 12/09 OSP 09 117029 REPORT OF VERIFIED CASE OF TUBERCULOSIS Page 1 of 3
Transcript of Supplemental Materials - Surveillance Forms
State of California—Health and Human Services Agency California Department of Public Health
Street Address
Patient’s Name (Last) (First) (M.I.)
REPORT OF VERIFIED CASE OF TUBERCULOSIS
(ZIP CODE)
State CodeYear Reported (YYYY) Locally Assigned Identification Number
REPORT OF VERIFIED CASE OF TUBERCULOSIS
1. Date Reported 3. Case Numbers
State Case Number
City/County Case Number
Linking State Case Number
Linking State Case Number
2. Date Submitted
Month Day Year
Month Day Year
Reason:
4. Reporting Address for Case Counting
City
Within City Limits (select one) Yes No
8. Date of Birth
Month Day Year
County 9. Sex at Birth (select one)
Male Female
11. Race (select one or more) American Indian or Alaska Native
White
Black or African American
Asian: Specify
Native Hawaiian or Other Pacific Islander: Specify
ZIP CODE 10. Ethnicity (select one)
Not Hispanic or Latino
Hispanic or Latino5. Count Status (select one)
Countable TB Case
Noncountable TB Case
Count as a TB case in your jurisdiction
Verified Case: Counted by another U.S. area (state)
Verified Case: Recurrent TB within 12 months after completion of therapy
Verified Case: TB treatment initiated in another country Specify
6. Date Counted Month Day Year
7. Previous Diagnosis of TB Disease (select one)
If YES, enter year of previous TB disease diagnosis:
Yes No
12. Country of Birth “U.S.-born” (or born abroad to a parent who was a U.S. citizen) (select one) Yes No
Country of birth: Specify
13. Month-Year Arrived in U.S. Year Month
14. Pediatric TB Patients (<15 years old) 16. Site of TB Disease (select all that apply)
15. Status at TB Diagnosis (select one)
Month Day Year
Country of Birth for Primary Guardian(s): Specify
Patient lived outside U.S. for >2 months? (select one)
If DEAD, enter date of death:
If DEAD, was death related to TB disease? (select one)
Bone and/or Joint
Genitourinary
Meningeal
Peritoneal
Other: Enter anatomic code(s) (see list):
Site not stated
Pulmonary
Pleural
Lymphatic: Cervical
Lymphatic: Intrathoracic
Lymphatic: Axillary
Lymphatic: Other
Lymphatic: Unknown
Laryngeal
Yes No Unknown
Yes No Unknown
Alive Dead
1
2
3
{
Guardian 1
Guardian 2
If YES, list countries, specify:
Public reporting burden of this collection of information is estimated to average 35 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed and completing and reviewing the collection of information. 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 D-74, Atlanta, CA 30333, ATTN: PRA (0920-0026). Do not send the completed form to this address.
Information contained on this form which would permit identification of any individual has been collected with a guarantee that it will be held in strict confidence, will be used only for surveillance purposes, and will not be disclosed or released without the consent of the individual in accordance with Section 308(d) of the Public Health Service Act (42 U.S.C. 242m).
CDPH 8620A (1/3) Rev. 12/09 OSP 09 117029 REPORT OF VERIFIED CASE OF TUBERCULOSIS Page 1 of 3
Patient’s Name State Case No. REPORT OF VERIFIED CASE (Last) (First) (M.I.) OF TUBERCULOSIS
REPORT OF VERIFIED CASE OF TUBERCULOSIS
23. Tuberculin (Mantoux) Skin Test at Diagnosis (select one)
25. Primary Reason Evaluated for TB Disease (select one)
24. Interferon Gamma Release Assay for Mycobacterium tuberculosis at Diagnosis (select one)
17. Sputum Smear (select one)
18. Sputum Culture (select one)
19. Smear/Pathology/Cytology of Tissue and Other Body Fluids (select one)
20. Culture of Tissue and Other Body Fluids (select one)
21. Nucleic Acid Amplification Test Result (select one)
Initial Chest Radiograph and Other Chest Imaging Study
22A. Initial Chest Radiograph (select one)
22B. Initial Chest CT Scan or Other Chest Imaging Study (select one)
Date Collected:
Month Day Year
Date Collected:
Month Day Year
Date Collected:
Month Day Year
Date Collected:
Normal
Normal
Abnormal* (consistent with TB)
Abnormal* (consistent with TB)
* For ABNORMAL Initial Chest Radiograph:
* For ABNORMAL Initial Chest Radiograph: Evidence of a cavity (select one):
Date Tuberculin Skin Test (TST) Placed: Millimeters (mm) of induration:
Evidence of miliary TB (select one):
Evidence of a cavity (select one):
Evidence of miliary TB (select one):
Month Day Year
Date Collected: Month Day Year
Month Day Year
Enter anatomic code (see list):
Enter anatomic code (see list):
Enter specimen type: OR If not Sputum, enter anatomic code (see list):
Month Day Year
Date Collected:
Date Result Reported:
Month Day Year
Date Result Reported:
Month Day Year
Date Result Reported: Month Day Year
TB Symptoms
Abnormal Chest Radiograph (consistent with TB)
Contact Investigation
Targeted Testing
Health Care Worker
Employment/Administrative Testing
Immigration Medical Exam
Incidental Lab Result
Unknown
Reporting Laboratory Type (select one): Public Health Laboratory
Commercial Laboratory Other
Reporting Laboratory Type (select one): Public Health Laboratory
Commercial Laboratory Other
Type of exam (select all that apply):
Smear Pathology/Cytology
Reporting Laboratory Type (select one):
Public Health Laboratory
Commercial Laboratory Other
Positive
Negative
Not Done
Unknown
Positive
Negative
Not Done
Unknown
Positive
Negative
Not Done
Unknown
Positive
Negative
Not Done
Unknown
Positive
Negative
Not Done
Sputum
Unknown
Indeterminate
Not DonePositive
Not Done
Not Done
Unknown Negative
Unknown
Unknown
Positive
Negative
Indeterminate
Not Done
Unknown
Yes No
Yes No Unknown
Yes No Unknown
Yes No Unknown
Unknown
Test type:
Specify
CDPH 8620A (2/3) Rev. 12/09 REPORT OF VERIFIED CASE OF TUBERCULOSIS Page 2 of 3
Patient’s Name State Case No. REPORT OF VERIFIED CASE (Last) (First) (M.I.) OF TUBERCULOSIS
REPORT OF VERIFIED CASE OF TUBERCULOSIS
Positive Refused
Negative Indeterminate
Federal Prison
If YES, (select one)
If YES, (select one)
State Prison
Local Jail
Juvenile Correction Facility
Alcohol or Drug Treatment Facility
Other Long-Term Care Facility
Not Seeking Employment (e.g. student, homemaker, disabled person)
Unknown
Migrant/Seasonal Worker
Other OccupationCorrectional Facility Employee
Contact of Infectious TB Patient (2 years or less)
Post-organ Transplantation
Isoniazid
No Yes Unk No Yes Unk No Yes Unk
Rifampin
Moxifloxacin
Cycloserine
Para-Amino Salicylic Acid
Ethionamide
Other
Other
Specify
Specify
Amikacin
Kanamycin
Capreomycin
Ciprofloxacin
Levofloxacin
Ofloxacin Rifapentine
Rifabutin
Streptomycin
Ethambutol
Pyrazinamide
Contact of MDR-TB Patient (2 years or less) Incomplete LTBI Therapy Other Specify
None
Missed Contact (2 years or less)
Diabetes Mellitus
End-Stage Renal Disease
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35CA. If arrived in the US within the last 12 months, did patient arrive with a TB A/B-notification?
If Yes, enter Alien Number:
Family/Fiancé Visa
Immigrant Visa
Student Visa
Employment Visa Unknown
Other Immigration Status
Asylee or Parolee Tourist Visa
Refugee
Immunosuppression (not HIV/AIDS)
TNF Antagonist Therapy
Unemployed
Retired
Hospital -Based Facility
Health Care Worker
Nursing Home Residential Facility
Mental Health Residential Facility
Test Done, Results Unknown
Unknown Not Offered
26. HIV Status at Time of Diagnosis (select one)
34. Additional TB Risk Factors (select all that apply)
35. Immigration Status at First Entry to the U.S. (select one)
36. Date Therapy Started
Comments:
37. Initial Drug Regimen (select one option for each drug)
33. Excess Alcohol Use Within Past Year
29. Resident of Long-Term Care Facility at Time of Diagnosis (select one)
30. Primary Occupation Within the Past Year (select one)
31. Injecting Drug Use Within Past Year 32. Non-Injecting Drug Use Within Past Year
28. Resident of Correctional Facility at Time of Diagnosis (select one)27. Homeless Within Past Year
(select one) (select one) (select one)
(select one)
Month Day Year
Unknown
No
Unknown
If YES, under custody of Immigration and Customs Enforcement? (select one)
State HIV/AIDS Patient Number:
If POSITIVE, enter:
City/County HIV/AIDS Patient Number:
Other Correctional Facility
Unknown
Yes No
Unknown Yes
Unknown Yes No Unknown Yes No Unknown Yes No
Yes No
Unknown Yes No
Unknown Yes No(select one)
B�
CDPH 8620A (3/3) Rev. 12/09 REPORT OF VERIFIED CASE OF TUBERCULOSIS Page 3 of 3
State of California—Health and Human Services Agency California Department of Public Health
Street Address
Patient’s Name (Last) (First) (M.I.)
(Number, Street, City, State) (ZIP CODE)
REPORT OF VERIFIED CASE OF TUBERCULOSIS
REPORT OF VERIFIED CASE OF TUBERCULOSIS
Initial Drug Susceptibility Report (Follow Up Report – 1)
State Case Number
City/County Case Number
Year Counted
Submit this report for all culture-positive cases.
38. Genotyping Accession Number
Isolate submitted for genotyping (select one):
Was drug susceptibility testing done? (select one)
If YES, enter date FIRST isolate collected for which drug susceptibility testing was done:
Enter specimen type:
Isoniazid Capreomycin
Ciprofloxacin
Levofloxacin
Ofloxacin
Moxifloxacin
Other Quinolones
Cycloserine
Para-Amino Salicylic Acid
Other
Other
Specify
Specify
Rifampin
Pyrazinamide
Ethambutol
Streptomycin
Rifabutin
Rifapentine
Ethionamide
Amikacin
Kanamycin
If NO or UNKNOWN, do not complete the rest of Follow Up Report – 1
If YES, enter genotyping accession number for episode:
39. Initial Drug Susceptibility Testing
40. Initial Drug Susceptibility Results (select one option for each drug)
Comments:
Month Day Year
No Yes Unknown
No Yes
Sputum
OR
If not Sputum, enter anatomic code (see list):
Resistant Susceptible Not Done Unknown Resistant Susceptible Not Done Unknown
Public reporting burden of this collection of information is estimated to average 35 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed and completing and reviewing the collection of information. 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 D-74, Atlanta, CA 30333, ATTN: PRA (0920-0026). Do not send the completed form to this address.
Information contained on this form which would permit identification of any individual has been collected with a guarantee that it will be held in strict confidence, will be used only for surveillance purposes, and will not be disclosed or released without the consent of the individual in accordance with Section 308(d) of the Public Health Service Act (42 U.S.C. 242m).
OSP 09 117028 REPORT OF VERIFIED CASE OF TUBERCULOSIS Follow Up Report -1 / Page 1 of 1 CDPH 8620B (1/1) Rev. 12/09
REPORT OF VERIFIED CASEOF TUBERCULOSIS
Street Address
Patient’s Name(Last) (First)
(Number, Street, City, State)
(M.I.)
(ZIP CODE)
REPORT OF VERIFIED CASE OF TUBERCULOSIS
REPORT OF VERIFIED CASE OF TUBERCULOSIS Follow Up Report - 2 / Page 1 of 2
Public reporting burden of this collection of information is estimated to average 35 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and main-taining the data needed and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless itdisplays 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,
Information contained on this form which would permit identification of any individual has been collected with a guarantee that it will be held in strict confidence, will be used only for surveillance purposes,and will not be disclosed or released without the consent of the individual in accordance with Section 308(d) of the Public Health Service Act (42 U.S.C. 242m).
41. Sputum Culture Conversion Documented (select one)
Did the patient move before starting or during TB therapy?
If YES, moved to where (select all that apply)
If moved out of the U.S., transnational referral? (select one)
(select one)
If YES, enter date specimen collected for FIRSTconsistently negative sputum culture:
If NO, enter reason for not documenting sputum culture conversion (select one):
42. Moved
43. Date Therapy Stopped
45. Reason Therapy Extended >12 months (select all that apply)
46. Type of Outpatient Health Care Provider (select all that apply)
44. Reason Therapy Stopped or Never Started (select one)
Comments:
StateCase Number
City/CountyCase Number
Year Counted
Month Day Year
Month Day Year
Rifampin Resistance
Local/State Health Department (HD)
Non-adherence
IHS, Tribal HD, or Tribal Corporation Inpatient Care Only Unknown
Clinically Indicated - other reasons
Adverse Drug Reaction
Private Outpatient
Failure
Institutional/Correctional Other
Other Specify
No Follow-upSputum Despite Induction
No Follow-up Sputum and No Induction
Completed Therapy If DIED, indicate cause of death (select one):Not TB
Died Related to TB disease
Related to TB therapy
Unrelated to TB disease
UnknownOther
Unknown
Lost
Uncooperative or Refused
Adverse Treatment Event
Unknown
Patient Refused Patient Lost to Follow-Up
Died
In state, out of jurisdiction (enter city/county):
Out of state (enter state)
Out of the U.S. (enter country)
No Yes Unknown
No Yes
No Yes
Case Completion Report
Submit this report for all cases in which the patient was alive at diagnosis.
(Follow Up Report – 2)
Specify Date Patient Received
Specify Date Patient Received
Specify Date Patient Received
Specify Date Patient Received
Specify Date Patient Received
Specify Date Patient Received
Specify Date Patient Received
Specify Date Patient Received
Other Specify
State of California—Health and Human Services Agency California Department of Public Health
OSP 09 117030
Project Clearance Officer, 1600 Clifton Road, MS D-74, Atlanta, CA 30333, ATTN: PRA (0920-0026). Do not send the completed form to this address.
CDPH 8620C (1/2) Rev. 12/09
REPORT OF VERIFIED CASEOF TUBERCULOSISPatient’s Name
(Last) (First) (M.I.)
REPORT OF VERIFIED CASE OF TUBERCULOSIS
REPORT OF VERIFIED CASE OF TUBERCULOSIS Follow Up Report -2 / Page 2 of 2
Public reporting burden of this collection of information is estimated to average 35 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and main-taining the data needed and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless itdisplays 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,
Information contained on this form which would permit identification of any individual has been collected with a guarantee that it will be held in strict confidence, will be used only for surveillance purposes,and will not be disclosed or released without the consent of the individual in accordance with Section 308(d) of the Public Health Service Act (42 U.S.C. 242m).
47. Directly Observed Therapy (DOT) (select one)
No, Totally Self-Administered
Yes, Totally Directly Observed
Yes, Both Directly Observed and Self-Administered
Unknown
Was follow-up drug susceptibility testing done? (select one)
If YES, enter date FINAL isolate collected for which drug susceptibilitytesting was done:
Enter specimen type:
Isoniazid Capreomycin
Ciprofloxacin
Levofloxacin
Ofloxacin
Moxifloxacin
Other Quinolones
Cycloserine
Para-Amino Salicylic Acid
Other
Other
Specify
Specify
Rifampin
Pyrazinamide
Ethambutol
Streptomycin
Rifabutin
Rifapentine
Ethionamide
Amikacin
Kanamycin
If NO or UNKNOWN, do not complete the rest of Follow Up Report – 2
Number of weeks of directly observed therapy (DOT)
48. Final Drug Susceptibility Testing
49. Final Drug Susceptibility Results (select one option for each drug)
Comments:
Month Day Year
No Yes Unknown
Sputum
OR
If not Sputum, enter anatomic code (see list):
Case Completion Report - Continued (Follow Up Report – 2)
Resistant Susceptible Not Done Unknown Resistant Susceptible Not Done Unknown
State Case No.
State of California—Health and Human Services Agency California Department of Public Health
OSP 09 117030
Project Clearance Officer, 1600 Clifton Road, MS D-74, Atlanta, CA 30333, ATTN: PRA (0920-0026). Do not send the completed form to this address.
CDPH 8620C (2/2) Rev. 12/09
A. Demographic
A1. Name (Last, First, Middle): A2. Alien #: A3. Visa type: A4. Initial U.S. entry date:
A5. Age: A6. Sex: A7. DOB:
___/___/______
A8. TB Class Based on Technical Instructions for Panel Physicians:
A9. Country of examination: A10. Country of birth:
A11a. Name in care of:
A11b. Phone number:
A11c. Address:
A12a. Sponsor agency name:
A12b. Phone number:
A12c. Address:
B. Jurisdictional Information
B1. Arrival jurisdiction: B2. Current jurisdiction:
C. U.S. Evaluation
C1. Date of first U.S. test or provider/clinic visit: _____/_____/________
Mantoux Tuberculin Skin Test (TST) in U.S. Interferon-Gamma Release Assay (IGRA) in U.S.
C2a. Was a TST administered in the U.S.?
Yes No Unknown
If YES, C2b. TST placement date: ____/_____/__________
Placement date uknown
C2c. TST mm: _____________ Unknown
C2d. TST interpretation:
Positive Negative
Unknown
C2e. History of Previous Positive TST:
Yes No Unknown
C3a. Was IGRA performed? Yes No Unknown
If YES, C3b. Date collected: ____/____/_____ Date unknown
_______ IUs/Spots
C3c. IGRA brand:
QuantiFERON® T-SPOT
Other (specify): __________________
C3d. Result: Positive Negative Indeterminate, Borderline, or
Invalid Unknown Equivocal
C3e. History of previous positive IGRA:
Yes No Unknown
U.S Review of Pre-Immigration CXR U.S. Domestic CXR Comparison
C4. Pre-immigration CXR available?
Yes No Unknown
C6a. U.S. domestic CXR done?
Yes No Unknown
If YES, C6b. Date of U.S. CXR: ____/____/_______
C8. U.S. domestic CXR comparison to pre-immigration CXR:
Stable
Worsening
Improving
Unknown
C5. U.S. interpretation of pre-immigration CXR:
Normal (Negative for TB)
Abnormal
Suggestive of TB
Non-TB Condition
Poor Quality/Not Interpretable
Unknown
C7. Interpretation of U.S. CXR:
Normal (Negative for TB)
Abnormal
Suggestive of TB
Non-TB Condition
Poor Quality/Not Interpretable
Unknown
Public reporting burden of this collection of information is estimated to average 30 minutes per individual, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. 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/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D¬74, Atlanta, Georgia 30333; ATTN: PRA (0920-1238).
Form approved
OMB Control No. 0920-1238 Expiration Date 06/30/2021
The EDN Tuberculosis Follow-Up Worksheet for Newly-Arrived Persons with Overseas Tuberculosis Classifications
oig2
Sticky Note
Unmarked set by oig2
1
2
3
The EDN Tuberculosis Follow-Up Worksheet for Newly-Arrived Persons with Overseas Tuberculosis Classifications
Alien #
U.S. Review of Pre-Immigration Treatment
C9a. Completed treatment pre-immigration? Yes No
Unknown
If YES, C9b. Treated for TB disease Treated for LTBI
Treated, but unknown if TB disease or LTBI
If Treated for TB disease, Treatment completed prior to panel physician examination
Treatment completed after panel physician diagnosis (DS 3030)
At designated DOT site
At non-designated DOT site
Other, specify:________________________________
C9c. Treatment start date: ___/___/____ Start date unknown
C9d. Treatment end date: ___/___/____ End date unknown
C9e. Report of treatment administered prior to panel physician examination:
Treatment documented on overseas medical history form (DS 3026)
Documented on DS forms & patient reported at panel physician examination
After U.S. arrival only, patient verbally reported treatment completion
Unknown
C9f. Standard TB treatment regimen was administered?
Yes No Unable to verify
C10a. Arrived to the U.S. on treatment?
Yes No
Unknown
Treated for TB disease Treated for LTBI If YES, C10b.
Start date unknown C10c. Start date: ___/___/____
C11a: Pre-Immigration treatment concerns?
Yes No
If YES, C11b. Select all that apply:
Treatment duration too short
Incorrect treatment regimen
Inadequate information provided
Lack of adequate diagnostics
Unknown DOT/adherence status
Other, please specify: ________________________
C12. U.S. Microscopy/Bacteriology* No *Covers all results regardless of sputa collection method. Sputa collected in U.S.? Yes
# Date Collected
___/___/_____
___/___/_____
___/___/_____
AFB Smear
Positive Negative
Not Done Unknown
Positive Negative
Not Done Unknown
Positive Negative
Not Done Unknown
Sputum Culture
NTM
Contaminated
Not Done
NTM
Contaminated
Not Done
NTM
Contaminated
Not Done
MTB Complex
Negative
Unknown
MTB Complex
Negative
Unknown
MTB Complex
Negative
Unknown
Drug Susceptibility Testing
MDR-TB Mono-RIF
Mono-INH Other DR
No DR Not Done
MDR-TB Mono-RIF
Mono-INH Other DR
No DR Not Done
MDR-TB Mono-RIF
Mono-INH Other DR
No DR Not Done
D. Evaluation Disposition in U.S. D1a. Evaluation disposition date in U.S.: ___/____/______ D1b. State/jurisdiction of evaluation disposition in U.S.: ______________
D2a. Evaluation disposition in U.S.:
Completed evaluation
D2b. If evaluation was completed, was treatment recommended?
No Yes
LTBI
Active TB
Initiated Evaluation / Not completed Did not initate evaluation
D2c. If evaluation was NOT completed, why not? Select all that apply.
Not Located Moved within U.S., transferred to:_______________________ State/jurisdiction
Lost to Follow-Up Moved outside U.S.
Refused Evaluation Died
Unknown Other, specify: _______________
D3. Diagnosis Class 0 - No TB exposure, not infected or Class 1 - TB exposure, no evidence of infection
Class 2 - TB infection, no disease Class 3 - TB, TB disease
Class 4 - TB, inactive disease Pulmonary Both sites Extra-pulmonary
The EDN Tuberculosis Follow-Up Worksheet for Newly-Arrived Persons with Overseas Tuberculosis Classifications
Alien #
D4. If diagnosed with TB disease: State Case Number: _____ _______________________________
RVCT # unknown* RVCT Reported* Year State RVCT # / TBLISS #
TBLISS # unknown* TBLISS Reported*
City/County Case Number: _____ _______________________________
Year State RVCT # / TBLISS #
*Note: Either the RVCT or TBLISS number may be reported.
E. U.S. Treatment for TB Disease or TB Infection
E1a. U.S. treatment initiated: Yes No Unknown
E1b. If NO, specify the reason. Select all that apply:
Patient declined against medical advice Lost to follow-up Moved within U.S., transferred to:______________ State/jurisdiction
Died Moved outside the U.S. Prior treatment completed (year: _________) Currently on treatment Treatment not offered based on Unknown
local clinic guidelines Contraindication for treatment Other, specify:_____________________________
E1c. If YES: Treated for TB disease Treated for LTBI
E2. Treatment start date: ___/____/_______ E3. State/jurisdiction of treatment in U.S.: ______________
E4. Specify initial LTBI regimen:
Isoniazid (9 months; 9H)
Isoniazid (6 months; 6H)
Isoniazid/Rifapentine (3 months; 3HP)
Isoniazid/Rifampin (INH+RIF; 4 months)
Rifampin (4 months; 4R)
Isoniazid/Rifampin/Ethambutol/Pyrazinamide (RIPE; 2 months; suspected TB disease)
Unknown
Other, specify: _________________________________________________________
E5a. U.S. treatment completed: Yes No Unknown
If NO, E5b. Specify the reason. Select all that apply:
Patient declined against medical advice Lost to follow-up Moved within U.S., transferred to:________
State/ Died Moved outside the U.S. Unknown jurisdiction
Dying (treatment stopped because of Adverse effect Other, specify: ______________________ imminent death, regardless of cause of
Not TB disease death) Developed TB [For Provider decision patient diagnosed with Pregnancy [For patient
LTBI] diagnosed with LTBI] E6. Date therapy stopped: _____/_____/_________
Specify reason therapy stopped:_____________________________________________________________________
F. Evaluation Site Information G. Treatment Site Information
Provider’s Name: Provider’s Name:
Clinic Name: Clinic Name:
Telephone Number: Telephone Number:
Same as evaluation site information
H. Comments
A. Demographic
A1. Name (Last, First, Middle): A2. Alien #: A3. Visa type: A4. Initial U.S. entry date:
A5. Age: A6. Sex: A7. DOB:
___/___/______
A8. TB Class Based on Technical Instructions for Panel Physicians:
A9. Country of examination: A10. Country of birth:
A11a. Name in care of:
A11b. Phone number:
A11c. Address:
A12a. Sponsor agency name:
A12b. Phone number:
A12c. Address:
B. Jurisdictional Information
B1. Arrival jurisdiction: B2. Current jurisdiction:
C. U.S. Evaluation
C1. Date of first U.S. test or provider/clinic visit: _____/_____/________
Mantoux Tuberculin Skin Test (TST) in U.S. Interferon-Gamma Release Assay (IGRA) in U.S.
C2a. Was a TST administered in the U.S.?
Yes No Unknown
If YES, C2b. TST placement date: ____/_____/__________
Placement date uknown
C2c. TST mm: _____________ Unknown
C2d. TST interpretation:
Positive Negative
Unknown
C2e. History of Previous Positive TST:
Yes No Unknown
C3a. Was IGRA performed? Yes No Unknown
If YES, C3b. Date collected: ____/____/_____ Date unknown
_______ IUs/Spots
C3c. IGRA brand:
QuantiFERON® T-SPOT
Other (specify): __________________
C3d. Result: Positive Negative Indeterminate, Borderline, or
Invalid Unknown Equivocal
C3e. History of previous positive IGRA:
Yes No Unknown
U.S Review of Pre-Immigration CXR U.S. Domestic CXR Comparison
C4. Pre-immigration CXR available?
Yes No Unknown
C6a. U.S. domestic CXR done?
Yes No Unknown
If YES, C6b. Date of U.S. CXR: ____/____/_______
C8. U.S. domestic CXR comparison to pre-immigration CXR:
Stable
Worsening
Improving
Unknown
C5. U.S. interpretation of pre-immigration CXR:
Normal (Negative for TB)
Abnormal
Suggestive of TB
Non-TB Condition
Poor Quality/Not Interpretable
Unknown
C7. Interpretation of U.S. CXR:
Normal (Negative for TB)
Abnormal
Suggestive of TB
Non-TB Condition
Poor Quality/Not Interpretable
Unknown
Public reporting burden of this collection of information is estimated to average 30 minutes per individual, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. 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/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D¬74, Atlanta, Georgia 30333; ATTN: PRA (0920-1238).
Form approved
OMB Control No. 0920-1238 Expiration Date 06/30/2021
The EDN Tuberculosis Follow-Up Worksheet for Newly-Arrived Persons with Overseas Tuberculosis Classifications
oig2
Sticky Note
Unmarked set by oig2
1
2
3
The EDN Tuberculosis Follow-Up Worksheet for Newly-Arrived Persons with Overseas Tuberculosis Classifications
Alien #
U.S. Review of Pre-Immigration Treatment
C9a. Completed treatment pre-immigration? Yes No
Unknown
If YES, C9b. Treated for TB disease Treated for LTBI
Treated, but unknown if TB disease or LTBI
If Treated for TB disease, Treatment completed prior to panel physician examination
Treatment completed after panel physician diagnosis (DS 3030)
At designated DOT site
At non-designated DOT site
Other, specify:________________________________
C9c. Treatment start date: ___/___/____ Start date unknown
C9d. Treatment end date: ___/___/____ End date unknown
C9e. Report of treatment administered prior to panel physician examination:
Treatment documented on overseas medical history form (DS 3026)
Documented on DS forms & patient reported at panel physician examination
After U.S. arrival only, patient verbally reported treatment completion
Unknown
C9f. Standard TB treatment regimen was administered?
Yes No Unable to verify
C10a. Arrived to the U.S. on treatment?
Yes No
Unknown
Treated for TB disease Treated for LTBI If YES, C10b.
Start date unknown C10c. Start date: ___/___/____
C11a: Pre-Immigration treatment concerns?
Yes No
If YES, C11b. Select all that apply:
Treatment duration too short
Incorrect treatment regimen
Inadequate information provided
Lack of adequate diagnostics
Unknown DOT/adherence status
Other, please specify: ________________________
C12. U.S. Microscopy/Bacteriology* No *Covers all results regardless of sputa collection method. Sputa collected in U.S.? Yes
# Date Collected
___/___/_____
___/___/_____
___/___/_____
AFB Smear
Positive Negative
Not Done Unknown
Positive Negative
Not Done Unknown
Positive Negative
Not Done Unknown
Sputum Culture
NTM
Contaminated
Not Done
NTM
Contaminated
Not Done
NTM
Contaminated
Not Done
MTB Complex
Negative
Unknown
MTB Complex
Negative
Unknown
MTB Complex
Negative
Unknown
Drug Susceptibility Testing
MDR-TB Mono-RIF
Mono-INH Other DR
No DR Not Done
MDR-TB Mono-RIF
Mono-INH Other DR
No DR Not Done
MDR-TB Mono-RIF
Mono-INH Other DR
No DR Not Done
D. Evaluation Disposition in U.S. D1a. Evaluation disposition date in U.S.: ___/____/______ D1b. State/jurisdiction of evaluation disposition in U.S.: ______________
D2a. Evaluation disposition in U.S.:
Completed evaluation
D2b. If evaluation was completed, was treatment recommended?
No Yes
LTBI
Active TB
Initiated Evaluation / Not completed Did not initate evaluation
D2c. If evaluation was NOT completed, why not? Select all that apply.
Not Located Moved within U.S., transferred to:_______________________ State/jurisdiction
Lost to Follow-Up Moved outside U.S.
Refused Evaluation Died
Unknown Other, specify: _______________
D3. Diagnosis Class 0 - No TB exposure, not infected or Class 1 - TB exposure, no evidence of infection
Class 2 - TB infection, no disease Class 3 - TB, TB disease
Class 4 - TB, inactive disease Pulmonary Both sites Extra-pulmonary
The EDN Tuberculosis Follow-Up Worksheet for Newly-Arrived Persons with Overseas Tuberculosis Classifications
Alien #
D4. If diagnosed with TB disease: State Case Number: _____ _______________________________
RVCT # unknown* RVCT Reported* Year State RVCT # / TBLISS #
TBLISS # unknown* TBLISS Reported*
City/County Case Number: _____ _______________________________
Year State RVCT # / TBLISS #
*Note: Either the RVCT or TBLISS number may be reported.
E. U.S. Treatment for TB Disease or TB Infection
E1a. U.S. treatment initiated: Yes No Unknown
E1b. If NO, specify the reason. Select all that apply:
Patient declined against medical advice Lost to follow-up Moved within U.S., transferred to:______________ State/jurisdiction
Died Moved outside the U.S. Prior treatment completed (year: _________) Currently on treatment Treatment not offered based on Unknown
local clinic guidelines Contraindication for treatment Other, specify:_____________________________
E1c. If YES: Treated for TB disease Treated for LTBI
E2. Treatment start date: ___/____/_______ E3. State/jurisdiction of treatment in U.S.: ______________
E4. Specify initial LTBI regimen:
Isoniazid (9 months; 9H)
Isoniazid (6 months; 6H)
Isoniazid/Rifapentine (3 months; 3HP)
Isoniazid/Rifampin (INH+RIF; 4 months)
Rifampin (4 months; 4R)
Isoniazid/Rifampin/Ethambutol/Pyrazinamide (RIPE; 2 months; suspected TB disease)
Unknown
Other, specify: _________________________________________________________
E5a. U.S. treatment completed: Yes No Unknown
If NO, E5b. Specify the reason. Select all that apply:
Patient declined against medical advice Lost to follow-up Moved within U.S., transferred to:________
State/ Died Moved outside the U.S. Unknown jurisdiction
Dying (treatment stopped because of Adverse effect Other, specify: ______________________ imminent death, regardless of cause of
Not TB disease death) Developed TB [For Provider decision patient diagnosed with Pregnancy [For patient
LTBI] diagnosed with LTBI] E6. Date therapy stopped: _____/_____/_________
Specify reason therapy stopped:_____________________________________________________________________
F. Evaluation Site Information G. Treatment Site Information
Provider’s Name: Provider’s Name:
Clinic Name: Clinic Name:
Telephone Number: Telephone Number:
Same as evaluation site information
H. Comments
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