Interjurisdictional Tuberculosis Notification Form
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1Interjurisdictional Tuberculosis Notification
Referring
Jurisdiction
Date sent
/
/
city
county
state
Contact person
Phone (
)
FAX (
)
Verified case→State reporting to CDC:
RVCT#
Not reported
(attach RVCT)
Suspect case
Close contact
Reactor (LTBI)
Convertor (LTBI)
Source case investigation
A/B Classified Immigrant
Patient name
Sex:
Male
Female
Last
First
Middle
AKA
Date of birth
/
/
Interpreter needed?
No
Yes, specify language
New address
Hispanic:
No
Yes
Number/Street/Apt.
Race:
White
Black
Asian
Am.Indian/Nat.Alaskan.
City/State/ZipCode
Other:
New telephone (
)
Date of expected arrival
/
/
New health provider:
Unknown
Known (name, address, phone)
Medicaid
Private
Medicare
Other
Insurance source:
None
Emergency contact: Name
Phone (
)
Relationship
this referred case/suspect
Clinical Information for:
index case for this contact
not applicable
Date of Collection
Specimen Type
Smear
Culture
Susceptibility
Chest X-ray
Other pertinent labs
Site(s) of disease:
Pulmonary
Other(s) specify all
st
st
Date 1
negative smear
/
/
Not yet
Date 1
negative culture
/
/
Not yet
TB skin test #1:
Date
/
/
Result
mm
TB skin test #2:
Date
/
/
Result
mm
QFT #1:
/
/
Result:
+
-
Indeterminate
QFT #2:
/
/
Result:
+
-
Indeterminate
Contact/LTBI Information
TST #1
Date
/
/
Result
mm
TST #2: Date
/
/
Result
mm
QFT #1:
/
/
Result:
+
-
Indeterminate
QFT #2:
/
/
Result:
+
-
Indeterminate
CXR: Date
/
/
Normal
Other:
Last known exposure to index case
/
/
Place/intensity of exposure:
Medications
this referred case/suspect
this referred contact/LTBI
Planned completion date
/
/
Drug
Dose
Start date
Stop date
DOT No Yes: start date
/
/
1x W
2x W
3x W
Daily
Last DOT
Date
/
/
Adherence problems/significant drug side effects:
Patient given
days of medication
For non-Class 3/5 referrals indicate if:
Follow-up requested
No follow-up requested
Comments
(Adapted from 2002 NTCA Form) / (UDOH, September 2010)
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