"Tuberculosis Surveillance Report Form" - Connecticut

Tuberculosis Surveillance Report Form is a legal document that was released by the Connecticut State Department of Public Health - a government authority operating within Connecticut.

Form Details:

  • Released on December 20, 2016;
  • The latest edition currently provided by the Connecticut State Department of Public Health;
  • Ready to use and print;
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Download "Tuberculosis Surveillance Report Form" - Connecticut

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Fax or mail to:
Tuberculosis Surveillance Report
Connecticut Department of Public Health
Complete for ALL TB Disease and
Tuberculosis Control Program
410 Capitol Avenue, MS #11TUB
Latent TB Infection
P.O. Box 340308
Hartford, CT 06134-0308
Phone: 860-509-7722 Fax: 860-509-7743
Patient Name – Last, First, Middle
Sex at Birth
Date of Birth
Best Phone Number
Alternate Phone
 Male
 Female
_____|_____|_______
 Other
MM
DD
YYYY
______________
(specify):
Street Address
City
State
Zip
Ever Served in U.S. Military
 Yes
 No
Race (select one or more)
Ethnicity (select one)
Preferred Language
 American Indian/Alaska Native
 Asian (specify): ______________
 Black or African American
 Hispanic or Latino/a
 White
 Native Hawaiian or Other Pacific Islander (specify): ________________________
_______________________
Not Hispanic or Latino/a
Country of Birth
Immigration Status at First Entry to the U.S.
 Student Visa
 Family/Fiance Visa
 Other Immigration Status
 Not applicable/U.S. born*
 Employment Visa
 Refugee
 Immigrant Visa
Month-Year Arrived in U.S.
* U.S. born or born abroad to a parent who was a U.S. citizen.
* Born in 1 of the U.S. territories, U.S. Island areas or U.S.
 Tourist Visa
 Asylee or Parolee
 Unknown
outlying areas
Patient’s Insurance Status
Pediatric TB Patients (<15 years old)
Country of Birth for Guardian(s)
Status at Diagnosis
(specify)
 Alive
 Dead
Patient lived outside U.S. for > 2 months?
Guardian 1: _____________________________
 Uninsured
 Private
 Date of death
:
 Yes
 No
 Medicare
 Other
(specify):
Guardian 2: _____________________________
____|____|_______
 Medicaid
If YES, specify countries: _________________
_______________
MM
DD
YYYY
Primary Occupation in the past 12 months
Most recent employer/school name:
 Health care worker
 Correctional employee
 Retired
 Migrant/Seasonal
 Not seeking employment
 Unemployed
Employer/school address:
(e.g. student, homemaker, disabled person)
worker
 Unknown
 Other occupation: ____________________________
SCREENING
Tuberculin (Mantoux) Skin Test
Interferon Gamma Release Assay for Mycobacterium Tuberculosis (IGRA):
(TST):
 Positive: ________________________
 Positive
 Indeterminate
 Negative
 Not Done
millimeters of induration
Date Collected:
Date Read:
 Negative
 Not done
_______|_______|__________
_______|_______|__________
Test Type
MM
DD
YYYY
MM
DD
YYYY
 QuantiFERON
 T-Spot.TB
History of Negative
?
Date of Last Negative TST
History of Latent TB Infection or TB Disease?
TST
?
 Disease
Year: ____________________
  Yes
 Infection
______|_______
Year: ____________________
  No
  None
MM
YYYY
IMAGING – ATTACH COPIES OF ALL IMAGING REPORTS
 CXR
 CT Scan
 MRI
Initial Chest Radiograph (CXR)
Other Imaging Study
Select one:
 Normal
 Normal
Date:
Date:
 Abnormal
 Abnormal
 Not Done
 Not Done
_______|_______|__________
_______|_______|__________
MM
DD
YYYY
MM
DD
YYYY
 Yes
 No
Evidence of a cavity
Evidence of a cavity
Yes
No
If ABNORMAL:
If ABNORMAL
:
 Yes
 No
Evidence of miliary
Evidence of miliary
TB
Yes
No
TB
BACTERIOLOGY RESULTS – ATTACH COPIES OF ALL RESULTS
#
Date Collected
Specimen Type
Smear
Nucleic Acid Amplification Test
Culture
 Positive
Rifampin resistant detected?
 Sputum
 Positive
 (+) MTB
 Negative
 Negative
 Yes
 Fluid (specify):______________
 Negative
1
 Indeterminate
 No
 Tissue (specify): ____________
 Pending
 Pending
 Non-TB sp.
____|_____|_____
 Not Done
 Not Done
MM
DD
YYYY
 Positive
Rifampin resistant detected?
 (+) MTB
 Negative
 Sputum
 Positive
 Negative
 Yes
 Fluid (specify):______________
 Negative
2
 Indeterminate
 No
 Tissue (specify): ____________
 Pending
 Pending
 Non-TB sp.
____|_____|_____
 Not Done
 Not Done
MM
DD
YYYY
 Positive
Rifampin resistant detected?
 (+) MTB
 Negative
 Sputum
 Positive
 Negative
 Yes
 Fluid (specify):______________
 Negative
3
 Indeterminate
 No
____|_____|_____
 Tissue (specify): _____________
 Pending
 Pending
 Non-TB sp.
 Not Done
 Not Done
MM
DD
YYYY
DIAGNOSIS & EVALUATION
Diagnosis
Reason for Evaluation
 TB Disease (specify site): ____________
 TB symptoms
 Abnormal chest radiograph consistent with TB disease
(onset date) ________|________|_________
MM
DD
YYYY
 Latent TB Infection
 Contact investigation
 Targeted testing
 Health care worker
 Employment/Administrative testing
 Class B1/B2 evaluation
 Immigration medical exam
 Incidental lab report
Rev. 12/20/2016
1
Fax or mail to:
Tuberculosis Surveillance Report
Connecticut Department of Public Health
Complete for ALL TB Disease and
Tuberculosis Control Program
410 Capitol Avenue, MS #11TUB
Latent TB Infection
P.O. Box 340308
Hartford, CT 06134-0308
Phone: 860-509-7722 Fax: 860-509-7743
Patient Name – Last, First, Middle
Sex at Birth
Date of Birth
Best Phone Number
Alternate Phone
 Male
 Female
_____|_____|_______
 Other
MM
DD
YYYY
______________
(specify):
Street Address
City
State
Zip
Ever Served in U.S. Military
 Yes
 No
Race (select one or more)
Ethnicity (select one)
Preferred Language
 American Indian/Alaska Native
 Asian (specify): ______________
 Black or African American
 Hispanic or Latino/a
 White
 Native Hawaiian or Other Pacific Islander (specify): ________________________
_______________________
Not Hispanic or Latino/a
Country of Birth
Immigration Status at First Entry to the U.S.
 Student Visa
 Family/Fiance Visa
 Other Immigration Status
 Not applicable/U.S. born*
 Employment Visa
 Refugee
 Immigrant Visa
Month-Year Arrived in U.S.
* U.S. born or born abroad to a parent who was a U.S. citizen.
* Born in 1 of the U.S. territories, U.S. Island areas or U.S.
 Tourist Visa
 Asylee or Parolee
 Unknown
outlying areas
Patient’s Insurance Status
Pediatric TB Patients (<15 years old)
Country of Birth for Guardian(s)
Status at Diagnosis
(specify)
 Alive
 Dead
Patient lived outside U.S. for > 2 months?
Guardian 1: _____________________________
 Uninsured
 Private
 Date of death
:
 Yes
 No
 Medicare
 Other
(specify):
Guardian 2: _____________________________
____|____|_______
 Medicaid
If YES, specify countries: _________________
_______________
MM
DD
YYYY
Primary Occupation in the past 12 months
Most recent employer/school name:
 Health care worker
 Correctional employee
 Retired
 Migrant/Seasonal
 Not seeking employment
 Unemployed
Employer/school address:
(e.g. student, homemaker, disabled person)
worker
 Unknown
 Other occupation: ____________________________
SCREENING
Tuberculin (Mantoux) Skin Test
Interferon Gamma Release Assay for Mycobacterium Tuberculosis (IGRA):
(TST):
 Positive: ________________________
 Positive
 Indeterminate
 Negative
 Not Done
millimeters of induration
Date Collected:
Date Read:
 Negative
 Not done
_______|_______|__________
_______|_______|__________
Test Type
MM
DD
YYYY
MM
DD
YYYY
 QuantiFERON
 T-Spot.TB
History of Negative
?
Date of Last Negative TST
History of Latent TB Infection or TB Disease?
TST
?
 Disease
Year: ____________________
  Yes
 Infection
______|_______
Year: ____________________
  No
  None
MM
YYYY
IMAGING – ATTACH COPIES OF ALL IMAGING REPORTS
 CXR
 CT Scan
 MRI
Initial Chest Radiograph (CXR)
Other Imaging Study
Select one:
 Normal
 Normal
Date:
Date:
 Abnormal
 Abnormal
 Not Done
 Not Done
_______|_______|__________
_______|_______|__________
MM
DD
YYYY
MM
DD
YYYY
 Yes
 No
Evidence of a cavity
Evidence of a cavity
Yes
No
If ABNORMAL:
If ABNORMAL
:
 Yes
 No
Evidence of miliary
Evidence of miliary
TB
Yes
No
TB
BACTERIOLOGY RESULTS – ATTACH COPIES OF ALL RESULTS
#
Date Collected
Specimen Type
Smear
Nucleic Acid Amplification Test
Culture
 Positive
Rifampin resistant detected?
 Sputum
 Positive
 (+) MTB
 Negative
 Negative
 Yes
 Fluid (specify):______________
 Negative
1
 Indeterminate
 No
 Tissue (specify): ____________
 Pending
 Pending
 Non-TB sp.
____|_____|_____
 Not Done
 Not Done
MM
DD
YYYY
 Positive
Rifampin resistant detected?
 (+) MTB
 Negative
 Sputum
 Positive
 Negative
 Yes
 Fluid (specify):______________
 Negative
2
 Indeterminate
 No
 Tissue (specify): ____________
 Pending
 Pending
 Non-TB sp.
____|_____|_____
 Not Done
 Not Done
MM
DD
YYYY
 Positive
Rifampin resistant detected?
 (+) MTB
 Negative
 Sputum
 Positive
 Negative
 Yes
 Fluid (specify):______________
 Negative
3
 Indeterminate
 No
____|_____|_____
 Tissue (specify): _____________
 Pending
 Pending
 Non-TB sp.
 Not Done
 Not Done
MM
DD
YYYY
DIAGNOSIS & EVALUATION
Diagnosis
Reason for Evaluation
 TB Disease (specify site): ____________
 TB symptoms
 Abnormal chest radiograph consistent with TB disease
(onset date) ________|________|_________
MM
DD
YYYY
 Latent TB Infection
 Contact investigation
 Targeted testing
 Health care worker
 Employment/Administrative testing
 Class B1/B2 evaluation
 Immigration medical exam
 Incidental lab report
Rev. 12/20/2016
1
Fax or mail to:
Tuberculosis Surveillance Report
Connecticut Department of Public Health
Tuberculosis Control Program
Complete for ALL TB Disease and
410 Capitol Avenue, MS #11TUB
Latent TB Infection
P.O. Box 340308
Hartford, CT 06134-0308
Phone: 860-509-7722 Fax: 860-509-7743
Patient Name: _____________________________________________
Last
First
HIV / HEPATITIS TESTING – ATTACH COPIES OF POSITVE RESULTS
HIV Test Date
HIV Test Results
Hepatitis Test Date
Tests performed:
Was patient positive for:
 Indeterminate
 B
 B
 Results pending
 Negative
______|_______|________
______|_______|______
 C
 C
 Refused
 Positive
MM
DD
YYYY
MM
DD
YYYY
RISK FACTORS
Resident of Long Term Care Facility at Time of Diagnosis?
Resident of Correctional Facility at Time of
Within past year has the patient:
Diagnosis?
 Yes
 No
 Yes
 No
 Been homeless?
 Yes
 No
If YES, please specify facility name and type:
If YES, specify facility:
 Used injection drugs?
 Yes
 No
_____________________________________________________
_________________________________________
 Used other drugs?
 Yes
 No
Resident of Correctional Facility at any time?
 Used excess alcohol?
 Yes
 No
_____________________________________________________
 Yes
 No
ADDITIONAL TB RISK FACTORS / MEDICAL CONDITIONS
 Contact of infectious TB patient
 Contact of MDR-TB patient (2 years or less)
If known case, give name of source case: _____________________
(2 years or less)
 Missed contact (2 years or
 Incomplete Latent TB infection treatment  Diabetes mellitus
less)
 Pregnant - Due date:
 End stage renal disease
 Immunosuppression (not HIV/AIDS)
 Post-organ transplant
_______|_________|__________
 Curent
 Tumor necrosis factor-alpha (TNF-α) antagonist therapy.
 Cancer
 Smoking, if yes
 None
 Former
Other medical conditions/comments:
TREATMENT
Initial treatment regimen – Please complete for all medications and dosages.
Are you requesting FREE
 Isoniazid
 Other___________________ ______ mg
Start Date:
___________ mg
medication from the DPH
Tuberculosis Program?
 Rifampin
 Other___________________ ______ mg
___________ mg
______|_______|________
MM
DD
YYYY
 Pyrazinamide
 Other___________________ ______ mg
 Yes
 No
___________ mg
 Ethambutol
___________ mg
Please specify NON-TB medications:
 Pyridoxine (B6)
___________ mg
__________________________ ______ mg
Expected Duration (months)
IF YES, PLEASE ATTACH A
 Rifapentine
___________ mg
__________________________ ______ mg
PRESCRIPTION.
 Rifabutin
___________ mg
__________________________ ______ mg
 Other __________________ __________ mg
__________________________ _______mg
 Yes
 No
Directly Observed Therapy Performed by:
Discharge/Treatment Plan Completed?
 Local Health Dept
 DPH
Copies sent to:
 Local Health Dept
 VNA
 DPH
 Other
________________
(specify)
PROVIDER INFORMATION
Was patient hospitalized?
Medical Record Number
Date Admitted
Date Discharged
 Yes If yes, discharge plan required
 No
______|_______|______
______|_______|_______
MM
DD
YYYY
MM
DD
YYYY
Admitting Hospital
Phone
Attending Physician
Beeper/Pager No./Cell
Outpatient Follow-up Physician for TB
Outpatient Facility
Phone
Address
Fax
Person Completing This Report
Phone
Date of This Report
______|_______|_______
MM
DD
YYYY
2
Rev. 12/20/2016
MAIL: White copy to CT Department of Public Health, Yellow copy to the Local Health Department, and Pink to the patient’s file.
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