Form Tb-34 - Report Of Verified Case Of Tuberculosis
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2WV-DTBE
REPORT OF VERIFIED CASE OF TUBERCULOSIS
NAME_________________________________________________________
TELEPHONE #__________________________________
ADDRESS:_____________________________________________________
SEX:____M ____F DATE OF BIRTH:________________
_____________________ZIP_____________COUNTY___________________
COUNTRY OF BIRTH:
Within City Limits: ___Yes ___No
_____ U.S.-BORN (or born abroad to U.S. citizen.)
HOMELESS WITHIN PAST YEAR: ____Yes ____No.
_____ Other (Specify)___________________________
RACE: ____Amer.Ind/Alask.Nav.
_____Asian: Specify_________________
Month/Year Arrived in U.S. ______________________
____Black
____Nav.Haw/Pac.Is: Specify__________ White______
PEDIATRIC TB PATIENTS (< 15 y/o)
ETHNIC ORIGIN: ______Hispanic ______Non-Hispanic
Country of Birth for Primary Guardian(s): Specify
SITE OF DISEASE:
Previous Dx of TB? ___Yes ___No
Guardian 1___________________________________
_____ Pulmonary
_____ Lymphatic: Cervical
Guardian 2___________________________________
_____ Pleural
_____ Lymphatic: Intrathoracic
Patient lived outside US > 2 mos? _____Yes _____No
_____ Laryngeal
_____ Lymphatic: Axillary
If YES, list countries, specify:_______________________
STATUS AT TB DIAGNOSIS: _____ Alive _____ Dead
_____ Bone / Joint
_____ Lymphatic: Other
_____ Genitourinary
_____ Peritoneal
If DEAD, date of death:_____________.
_____ Meningeal
_____ Other (Specify) _________________
TB cause of death? ____ Yes ____ No
SPUTUM:
Smear: _____ Positive
Culture: _____Positive
Result
Type of Lab: _____Public Health
Collected:___________
_____ Negative
_____Negative
Reported:___________
_____Commercial
_____ Not Done
_____Not Done
_____Other
TISSUE AND OTHER BODY FLUIDS:
Specimen type:______________________________ Collected:_____________
Type of Exam:
____Positive
Culture: ____Positive
Result
Type of Lab: _____Public Health
____Smear
____Negative
____Negative
Reported:___________
_____Commercial
____Pathology/Cytology
____Not Done
____Not Done
_____Other
NUCLEIC ACID AMPLIFICATION TEST RESULT: Specimen type:__________________
_____ Positive
_____ Indeterminate
Collected:_______________
Type of Lab: ______Public Health
_____ Negative _____ Not Done
Reported:_______________
______Commercial
_____Other
INITIAL CHEST RADIOGRAPH AND OTHER CHEST IMAGING STUDY
Chest X-ray: DATE:_____________
_____ Normal
_____ Abnormal (consistent with TB)
_____Not Done
For ABNORMAL Initial Chest X-ray: Evidence of a Cavity? ____Yes ____No; Evidence of miliary TB? ____Yes ____No
Other Chest
DATE:_____________
_____ Normal
_____ Abnormal (consistent with TB)
_____Not Done
Imaging:
For ABNORMAL Initial Chest X-ray: Evidence of a Cavity? ____Yes ____No; Evidence of miliary TB? ____Yes ____No
TUBERCULIN (Mantoux) SKIN TEST AT DIAGNOSIS:
PRIMARY REASON EVALUATED FOR TB DISEASE (
select one ):
_____Positive
_______ mms
Date given:________________
____ TB Symptoms
_____Negative
_____ Not Done
____ Abn. CXR (consistent with TB)
INTERFERON GAMMA RELEASE ASSAY FOR MTB AT DIAGNOSIS:
____ Contact Investigation
_____Positive
____Indeterminate
Collected:_________________
____ Targeted Testing
_____Negative ____Not Done
Type_____________________
____ Health Care Worker
HIV STATUS AT TIME OF DIAGNOSIS: (select one)
____ Employment/Administrative Testing
____Negative
____Indeterminate
____Not Offered
____ Immigration Medical Exam
____Positive
____Refused
____Test Done, Results Unknown
____ Incidental Lab Result
If POSITIVE, enter State HIV/AIDS #: __ __ __ __ __ __ __ __ __ __
RESIDENT OF CORRECTIONAL FACILITY AT TIME OF DIAGNOSIS: ____ No ____YES
If YES, under custody of Immigration
If YES, (
Federal Prison
____State Prison
____Local Jail
and Customs Enforcement?
select one ) _____
____Juvenile Correctional Facility
____Other Corr. Facility
_____No
____Yes
RESIDENT OF LONG-TERM CARE FACILITY AT TIME OF DIAGNOSIS
____No
If YES,
____Nursing Home
____Residential Facility
____Alcohol/ Drug Treatment Facility
____YES
____Hospital-Based Facility
____Mental Health Residential Facility
____Other LTC Facility
TB-34 (Rev 09-01-2009)
REPORT OF VERIFIED CASE OF TUBERCULOSIS Page 1 of 2
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