Form Tb Ndr - Notifiable Disease Report For Tuberculosis - Hawaii State Department Of Health
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1
2MAIL OR FAX TO:
NOTIFIABLE DISEASE REPORT FOR TUBERCULOSIS
Hawaii Tuberculosis Control Program
Hawaii State Department of Health
ATTN: TB REGISTRY DEPARTMENT
Tuberculosis Control Program
1700 Lanakila Avenue, Honolulu, HI 96817
FAX: (808) 832-5624
PHONE: (808) 832-5731
1. Name: ____________________________________________________________________________
6. Date of Birth: _____/_____/__________
LAST
FIRST
MIDDLE INITIAL
MM
DD
YYYY
7. SSN (
):
LAST 4 DIGITS
2. Address: __________________________________________________________________________
STREET NUMBER and STREET NAME
□
□
8. Sex at Birth :
Male
Female
__________________________________________________________________________
□
□
□
CITY, STATE, and ZIP CODE
9. U.S. Citizen:
No
Yes
Unknown
□
□
□
3. Homeless Within Past Year:
No
Yes
Unknown
10. Place of Birth: ___________________________
4. Home Phone: ___________________ Cellular: ___________________ Work: ___________________
11. Foreign Born:
Date Arrived in U.S.: _____/_____/__________
5. Next of Kin: ________________________ Relationship: ______________ Phone: ________________
□
□
12. Primary Occupation Within the Past Year (
):
Unknown
Other (
): ______________________________________________
SELECT ONE
SPECIFY
□
□
□
Unemployed
Health Care Worker
Correctional Facility Employee
□
□
□
Retired
Migrant/Seasonal Worker
Not Seeking Employment (
)
E.G., INFANT, CHILD, STUDENT, HOMEMAKER, DISABLED PERSON
13. Race / Ethnicity (
):
CHECK ALL THAT APPLY
□
□
□
□
□
□
□
□
African American
Carolinian
Chinese
Guamanian
Japanese
Marshallese
Palauan
Tongan
□
□
□
□
□
□
□
□
Alaskan Native
Caucasian
Chuukese
Hawaiian
Korean
Micronesian
Pohnpeian
Vietnamese
□
□
□
□
□
□
□
□
American Indian
Chamorro
Filipino
Hispanic
Kosraean
Okinawan
Samoan
Yapese
□
Other (
): ______________________________________________________________________________________________________________
SPECIFY
□
□
14. Reason Evaluated for TB (
):
TB Symptoms
Abnormal Chest Radiograph (Incidental Finding)
SELECT ONE
□
□
□
TB Contact Investigation
Health Care Worker Screening
DOH Mandated TB Screening (
): _________________________
CATEGORY
□
□
□
Immigration Medical Exam
Lab Result (Incidental Finding)
Other (
): ______________________________________________
SPECIFY
□
15. Date of Diagnosis: _____/_____/__________
17. Previous TB Disease
18. Site(s) of TB Disease (
):
Lymphatic: Unknown
CHECK ALL THAT APPLY
□
□
□
□
□
□
□
Suspect
Confirmed
No
Yes
Pulmonary
Lymphatic: Intrathoracic
Bone
Joint
AND/OR
□
□
□
16. Status at Diagnosis of TB:
IF YES, Enter Year of
Pleural
Lymphatic: Cervical
Genitourinary
□
□
Previous TB Disease:
□
□
□
Alive
Dead
Laryngeal
Lymphatic: Axillary
Peritoneal
□
□
□
Date of Death: _____/_____/__________
Meningeal
Lymphatic: Other
Other: ________________
SMEAR RESULT
NUCLEIC ACID
SPECIMEN TYPE & SITE
DRUG SUSCEPTIBILITY RESULTS
DATE
IF POSITIVE, ENTER
(E.G., SPUTUM, TISSUE, PLEURAL
CULTURE
IF CULTURE POSITIVE FOR MTB,
AMPLIFICATION
SMEAR COUNT
COLLECTED
FLUID, ETC.)
(E.G., MTD DIRECT)
INDICATE DRUG RESISTANCE
(E.G., 1+, 2+, 3+, 4+)
□
□
□
□
□
□
□
□
□
Type:
NEG
POS _____
NEG
POS
PEND
NEG
MTB COMPLEX
PEND
PAN SUSCEPTIBLE
/
/
□
□
□
□
□
(
): ___________
Site:
PENDING
PEND
INDET
NOT TB
RESISTANT TO: _____________
SPECIFY ID
□
□
□
□
□
□
□
□
□
Type:
NEG
POS _____
NEG
POS
PEND
NEG
MTB COMPLEX
PEND
PAN SUSCEPTIBLE
/
/
□
□
□
□
□
(
): ___________
Site:
PENDING
PEND
INDET
NOT TB
RESISTANT TO: _____________
SPECIFY ID
□
□
□
□
□
□
□
□
□
Type:
NEG
POS _____
NEG
POS
PEND
NEG
MTB COMPLEX
PEND
PAN SUSCEPTIBLE
/
/
□
□
□
□
□
(
): ___________
Site:
PENDING
PEND
INDET
NOT TB
RESISTANT TO: _____________
SPECIFY ID
□
□
□
□
□
□
□
□
□
Type:
NEG
POS _____
NEG
POS
PEND
NEG
MTB COMPLEX
PEND
PAN SUSCEPTIBLE
/
/
□
□
□
□
□
(
): ___________
Site:
PENDING
PEND
INDET
NOT TB
RESISTANT TO: _____________
SPECIFY ID
□
21. Interferon Gamma Release Assay (IGRA) (
):
20. Tuberculin Skin Test (TST) at Diagnosis:
Not Done
E.G., QUANTIFERON AND T-SPOT.TB
□
□
□
□
□
Not Done
Negative
Positive
Indeterminate
Negative -- Date TST Placed: ____/____/_______ Induration: ____ mm
□
Date Collected: ____/____/_______ Type of IGRA (
): ___________
Positive -- Date TST Placed: ____/____/_______ Induration: ____ mm
SPECIFY
TB NDR (Rev. 1/2009)
PAGE 1 OF 2
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