Instructions for "Tuberculosis Surveillance Report Form" - Connecticut

This document was released by Connecticut State Department of Public Health and contains official instructions for Tuberculosis Surveillance Report Form. The up-to-date fillable form is available for download through this link.

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Download Instructions for "Tuberculosis Surveillance Report Form" - Connecticut

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INSTRUCTIONS FOR SUBMITTING
TUBERCULOSIS SURVEILLANCE REPORTS
Updated January 2017
NEW: The Department of Public Health has revised and combined the forms for reporting Tuberculosis
(TB) disease and latent TB infection (formerly, the TB-86 and LTBI forms). The new, combined, two-page
form is now called the Tuberculosis Surveillance Report.
WHAT TO REPORT:
 Tuberculosis (TB) Disease, confirmed or suspected:
Please report persons with positive acid fast bacilli (AFB) smears; persons with clinical or
radiographic evidence of TB; or persons started on at least two anti-TB medications as well as
persons with positive cultures or nucleic acid amplification tests (NAAT) for Mycobacterium
tuberculosis.
 Latent Tuberculosis Infection (LTBI):
Please report a (+) tuberculin skin test (TST) or interferon gamma release assay (IGRA) for M.
tuberculosis and a chest X-ray that is normal or not consistent with active disease in: a person with
HIV co-infection; children ≤5 years old; recent immigrants/refugees; and anyone for whom
medication is requested.
Medical consultation for all TB-related diagnosis and treatment questions is available through the DPH TB
Control Program.
HOW AND WHEN TO REPORT:
 TB disease: Immediately by fax/telephone on day of recognition or suspicion. The Tuberculosis
Surveillance Report Form should be sent to both the local health director where the patient resides and
the DPH TB Control Program (ph: 860-509-7722, fax: 860-509-7743)
 LTBI: The Tuberculosis Surveillance Report form should be faxed or mailed to both the local health director
where the patient resides and the DPH TB Control Program within 48 hours of diagnosis.
Both pages of the report form should be completed in its entirety for both TB disease and LTBI patients.
Completed forms may be faxed or mailed (in an envelope marked “Confidential”) to:
DPH Tuberculosis Control Program
410 Capitol Ave. MS#11TUB
P.O. Box 340308
Hartford, CT 06134-0308
Fax: (860) 509-7743
All forms are also available on the Department of Public Health website at
http://www.ct.gov/dph/forms.
A limited number of forms can be requested by phone at (860) 509-7722.
INSTRUCTIONS FOR SUBMITTING
TUBERCULOSIS SURVEILLANCE REPORTS
Updated January 2017
NEW: The Department of Public Health has revised and combined the forms for reporting Tuberculosis
(TB) disease and latent TB infection (formerly, the TB-86 and LTBI forms). The new, combined, two-page
form is now called the Tuberculosis Surveillance Report.
WHAT TO REPORT:
 Tuberculosis (TB) Disease, confirmed or suspected:
Please report persons with positive acid fast bacilli (AFB) smears; persons with clinical or
radiographic evidence of TB; or persons started on at least two anti-TB medications as well as
persons with positive cultures or nucleic acid amplification tests (NAAT) for Mycobacterium
tuberculosis.
 Latent Tuberculosis Infection (LTBI):
Please report a (+) tuberculin skin test (TST) or interferon gamma release assay (IGRA) for M.
tuberculosis and a chest X-ray that is normal or not consistent with active disease in: a person with
HIV co-infection; children ≤5 years old; recent immigrants/refugees; and anyone for whom
medication is requested.
Medical consultation for all TB-related diagnosis and treatment questions is available through the DPH TB
Control Program.
HOW AND WHEN TO REPORT:
 TB disease: Immediately by fax/telephone on day of recognition or suspicion. The Tuberculosis
Surveillance Report Form should be sent to both the local health director where the patient resides and
the DPH TB Control Program (ph: 860-509-7722, fax: 860-509-7743)
 LTBI: The Tuberculosis Surveillance Report form should be faxed or mailed to both the local health director
where the patient resides and the DPH TB Control Program within 48 hours of diagnosis.
Both pages of the report form should be completed in its entirety for both TB disease and LTBI patients.
Completed forms may be faxed or mailed (in an envelope marked “Confidential”) to:
DPH Tuberculosis Control Program
410 Capitol Ave. MS#11TUB
P.O. Box 340308
Hartford, CT 06134-0308
Fax: (860) 509-7743
All forms are also available on the Department of Public Health website at
http://www.ct.gov/dph/forms.
A limited number of forms can be requested by phone at (860) 509-7722.