"Latent Tuberculosis Infection (Ltbi) Report Form" - Vermont

Latent Tuberculosis Infection (Ltbi) Report Form is a legal document that was released by the Vermont Department of Health - a government authority operating within Vermont.

Form Details:

  • Released on April 1, 2019;
  • The latest edition currently provided by the Vermont Department of Health;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the Vermont Department of Health.

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Latent Tuberculosis Infection (LTBI) Report Form
VDH Use Only:
#___________
Reporting Information
Date of report:
__ __/__ __ /__ __
Name of person reporting:
________________________
Phone:
(__ __ __) __ __ __ - __ __ __ __
Facility/Institution:
______________________________
Provider (if not reporter):
________________________
Street address:
____________________________________________
Town:
___________________________________________________
State:
__ __
Zip:
__ __ __ __ __
Patient Information
Last name: ___________________________
First name: ________________________
MI: ____
Street address:
________________________________________________
Town: ___________________________
State: __ __
Zip: __ __ __ __ __
Phone: (__ __ __) __ __ __ - __ __ __ __
Sex:
□ Male
□ Female
□ No answer
Date of birth: __ __/__ __ /__ __ __ __
Country of birth: _________________________
Is this person a contact to an active TB case?:
□ Yes
□ No
Ethnicity
Race (select all that apply)
□ Hispanic or Latino
□ American Indian or Alaska Native
□ Asian
□ Black or African American
□ Not Hispanic or Latino
□ White
□ Native Hawaiian or other Pacific Islander
□ Unknown
□ Unknown
Diagnosis Information
Reason for TB Evaluation (select all that apply)
□ TB signs or symptoms
□ Health care worker
□ Immigrant or refugee
□ Homeless
□ Resident of congregate setting
□ Contact to active TB case
□ Testing for school
□ Testing for employment
□ Immunosuppression or immunosuppressive treatment
□ Other:
____________________________________
Interferon Gamma Release Assay (IGRA)
Date collected:
__ __/__ __ /__ __
Test type:
□ QFT
□ T-SPOT
□ Other
Result:
□ Negative
□ Positive
□ Indeterminate
□ Unknown
□ Not done
Tuberculin Skin Test (TST)
Date placed:
__ __/__ __ /__ __
Date read:
__ __/__ __ /__ __
Millimeters of duration: _______
Interpretation:
□ Negative
□ Positive
□ Unknown
□ Not done
Chest x-ray
Date:
__ __/__ __ /__ __
Result:
□ Normal
□ Abnormal
Treatment Plan
Fax or mail completed form.
Fax: (802) 951-4061
Mail: 108 Cherry St. Suite 304 Burlington, VT 05401
Ver. 1
April 2019
Direct que stions t o the Inf ectious Disease Epidem iology P rogram at (802 ) 863-72 40.
Latent Tuberculosis Infection (LTBI) Report Form
VDH Use Only:
#___________
Reporting Information
Date of report:
__ __/__ __ /__ __
Name of person reporting:
________________________
Phone:
(__ __ __) __ __ __ - __ __ __ __
Facility/Institution:
______________________________
Provider (if not reporter):
________________________
Street address:
____________________________________________
Town:
___________________________________________________
State:
__ __
Zip:
__ __ __ __ __
Patient Information
Last name: ___________________________
First name: ________________________
MI: ____
Street address:
________________________________________________
Town: ___________________________
State: __ __
Zip: __ __ __ __ __
Phone: (__ __ __) __ __ __ - __ __ __ __
Sex:
□ Male
□ Female
□ No answer
Date of birth: __ __/__ __ /__ __ __ __
Country of birth: _________________________
Is this person a contact to an active TB case?:
□ Yes
□ No
Ethnicity
Race (select all that apply)
□ Hispanic or Latino
□ American Indian or Alaska Native
□ Asian
□ Black or African American
□ Not Hispanic or Latino
□ White
□ Native Hawaiian or other Pacific Islander
□ Unknown
□ Unknown
Diagnosis Information
Reason for TB Evaluation (select all that apply)
□ TB signs or symptoms
□ Health care worker
□ Immigrant or refugee
□ Homeless
□ Resident of congregate setting
□ Contact to active TB case
□ Testing for school
□ Testing for employment
□ Immunosuppression or immunosuppressive treatment
□ Other:
____________________________________
Interferon Gamma Release Assay (IGRA)
Date collected:
__ __/__ __ /__ __
Test type:
□ QFT
□ T-SPOT
□ Other
Result:
□ Negative
□ Positive
□ Indeterminate
□ Unknown
□ Not done
Tuberculin Skin Test (TST)
Date placed:
__ __/__ __ /__ __
Date read:
__ __/__ __ /__ __
Millimeters of duration: _______
Interpretation:
□ Negative
□ Positive
□ Unknown
□ Not done
Chest x-ray
Date:
__ __/__ __ /__ __
Result:
□ Normal
□ Abnormal
Treatment Plan
Fax or mail completed form.
Fax: (802) 951-4061
Mail: 108 Cherry St. Suite 304 Burlington, VT 05401
Ver. 1
April 2019
Direct que stions t o the Inf ectious Disease Epidem iology P rogram at (802 ) 863-72 40.