Active Tuberculosis Case Report Form - Public Health Agency Of Canada
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11.
Public Health
Agence de la santé
Active Tuberculosis Case Report Form –
Agency of Canada
publique du Canada
New and Re-treatment Cases
CONFIDENTIAL
EFFECTIVE JANUARY 2011
WHEN COMPLETED
Province/Territory/Patient ID
1. Reporting province/
2. Register case number
3. Unique identifier
4. Date of birth
5. Sex
Male
Female
territory
Year
Month
Day
1
2
Postal code
6. Usual residence
City/Town/Village
County and Health Unit
Lives on First Nation’s reserve most of the time?
1
Yes
2
No
8
N/A
9
Unknown
Origin
Origin
7. Canadian born?
N
6
Foreign-born
Y
Country of birth
Unknown
Y
Year
1
Status Indian (Registered)
2
Métis
Year of arrival in Canada
Temporary resident:
3
Inuit
4
Other Aboriginal (specify)
5
Work
6
Student
7
Visitor
Immigration status at the time of diagnosis:
1
Canadian citizen/Permanent resident
8
Immigration status – Other
Canadian born
5
Country of
non-Aboriginal
If other, specify:
birth of mother
3
Convention refugee
Under
Y
Y
2
Refugee
Y
Country of
age 15?
4
Refugee claimant
birth of father
9
Unknown
Diagnosis
8. Provincial/territorial case date
ICD 9
Year
Month
Day
ICD 10
9. Chest X-Ray
1
Normal
2
Abnormal
3
Not done
9
Unknown
If abnormal
1
Cavitary
2
Non-cavitary
Bacterial Status
10. Microscopy
11. Culture
Bronchial
Node
Bronchial
Node
Sputum
Wash
GI Wash
Biopsy
Urine
CSF
Other
Sputum
Wash
GI Wash
Biopsy
Urine
CSF
Other
Negative
Negative
Positive
Positive
Not done
Not done
Unknown
Unknown
12. Case Criteria
1
Culture positive
2
Clinical diagnosis
13. If initial positive culture – Antibiotic resistance?
Other (specify)
Drug
Drug
Result: Susceptible Resistant Not done Unknown
Result:
Susceptible Resistant Not done Unknown
Result
DRUG
Susceptible Resistant Not done Unknown
PAS
Streptomycin
INH
Kanamycin
Rifabutin
EMB
Capreomycin
Amikacin
RMP
Moxifloxacin
Ofloxacin
Unknown
PZA
Ethionamide
Linezolid
14. Genotyping results?
1
Yes
2
No
9
Unknown
Spoligo Octal Code
MIRU
RFLP
1
Yes
2
No
Treatment Details
15. Date treatment started
16. Initial drugs prescribed
(check all that apply)
No drugs prescribed
Streptomycin
Ethionamide
Moxifloxacin
Other (specify)
INH
RMP
Kanamycin
PAS
Linezolid
Year
Month
Day
Capreomycin
Rifabutin
EMB
PZA
Unknown
Ofloxacin
Amikacin
17. Death before or during treatment?
1
TB was the cause of death
TB contributed to death but was not the
2
Year
Month
Day
underlying cause
1
Yes
2
No
9
Unknown
If yes, date of death
3
TB did not contribute to death
TB History/Case Finding/Risk Factors/Markers
18. First episode of TB disease?
Previous diagnosis occured in:
Previous treatment completed or cured:
1
Yes
2
No
If no:
Year of previous
1
Yes
2
No
9
Unknown
1
Canada
diagnosis
If yes, end date
Year
Month
Day
2
Other country:
of previous
Previous treatment with (check all antibiotics used):
treatment:
20. Risk factors/Markers
INH
EMB
RMP
PZA
Year
st
If positive, year of 1 positive test
HIV
1
Positive
2
Negative
If negative, year of most recent test
Streptomycin
Ethionamide
Moxifloxacin
3
Test refused
4
Test not offered
5
Unknown
Kanamycin
PAS
Linezolid
Capreomycin
Rifabutin
Contact with person with active TB in past
1
Yes
2
No
9
Unknown
Ofloxacin
Amikacin
2 years
Other (specify)
Diabetes mellitus type 1 or 2
1
Yes
2
No
9
Unknown
Unknown
End-stage renal disease
1
Yes
2
No
9
Unknown
19. Case finding
Homeless
1
Yes
2
No
9
Unknown
(at diagnosis or within the previous 12 months)
Symptoms compatible
1
2
Incidental finding
Lives in correctional setting at time of diagnosis
1
Yes
2
No
9
Unknown
with site of disease
Contact
Long-term ( 1 month) corticosteroid use
4
3
Post-mortem
1
Yes
2
No
9
Unknown
investigation
(prednisone
15 mg/day or equivalent)
Previous abnormal chest x-ray
Occupational
Immigration
7
1
Yes
2
No
9
Unknown
5
(fibronodular disease)
screening
medical surveillance
Substance abuse (known or suspected)
Initial immigration medical
1
Yes
2
No
9
Unknown
8
Other screening
1
exam done outside Canada
1
Yes
2
No
9
Unknown
Transplant related immunosuppression
Other (specify)
Initial immigration medical
9
2
exam done inside Canada
Travel to high incidence TB country in last 2 years
1
Yes
2
No
9
Unknown
If yes, how long _________ (in weeks)
10
Unknown
1
Yes
2
No
9
Unknown
Other (specify)
PHAC/ASPC 9012E (01-2011)
DISPONIBLE EN FRANÇAIS
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