Edn Tb Follow-Up Worksheet
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EDN TB Follow-Up Worksheet
Last reviewed: 6/21/2013
A. Demographic
A2. Alien #:
A3. Visa type:
A4. Initial U.S. entry date:
A1. Name (Last, First, Middle):
,
A5. Age:
A6. Gender:
A7. DOB:
A8. TB Class:
___/___/______
A9.Country of examination:
A10.Country of birth:
A12. a. Sponsor agency name:
A11a. Address:
A11b. Phone:
b. Phone(s):
A11c. Other:
c. Address:
B. Jurisdictional Information
B1. Arrival jurisdiction:
B2. Current jurisdiction:
C. U.S. Evaluation
C1. Date of Initial U.S. medical evaluation:
___/___/______
Mantoux Tuberculin Skin Test (TST)
Interferon-Gamma Release Assay (IGRA)
C2a. Was a TST administered?
Yes
Unknown
C3a. Was IGRA administered?
Yes
No
No
Unknown
If YES,
If YES,
C3b. Date collected:
___/___/______
Date unknown
C2b. TST placement date:
___/___/______
Placement date unknown
C3c. IGRA brand:
QuantiFERON®
T-SPOT
C2c. TST mm:
_____________
Unknown
Other (specify):
C3d. Result:
C2d. TST interpretation:
Positive
Negative
Positive
Negative
Indeterminate
Unknown
Invalid
Unknown
C3e. History of previous positive IGRA
C2e. History of Previous Positive TST
Reset IGRA
Reset TST
U.S Review of Pre-Immigration CXR
U.S. Domestic CXR
Comparison
C11. U.S. domestic
C4. Pre-immigration CXR available?
C7. U.S. domestic CXR done?
CXR comparison to
Yes
No
Unknown
Yes
No
Not Verifiable
pre-immigration CXR:
C8. Date of U.S. CXR: ___/___/______
If YES,
C5. U.S. interpretation of pre-immigration CXR:
Stable
Normal
C9. Interpretation of U.S. CXR:
Worsening
Normal
Abnormal (must select one below):
Improving
Not consistent with active TB
Abnormal (must select one below):
Unknown
Non-cavitary, consistent with TB
Not consistent with active TB
Cavitary, consistent with TB
Non-cavitary, consistent with TB
Poor Quality
Cavitary, consistent with TB
Unknown
Unknown
Reset CXR
C6. Other pre-immigration CXR abnormalities:
C10. U.S. domestic CXR abnormalities:
Infiltrate
Granuloma(ta)
Volume loss
Infiltrate
Granuloma(ta)
Volume loss
Other (specify)
Other (specify)
Adenopathy
Adenopathy
U.S. Review of Pre-Immigration Treatment
Yes
No
C12a. Completed treatment pre-immigration?
C13. Arrived on treatment?
Yes
No
If YES,
Treated for TB disease
Treated for LTBI
Unknown
C12b. Treatment start date: ___/___/____
Start date unknown
TB disease
LTBI
If YES,
__
End date unknown
C12c. Treatment end date: ___/___/____
Start date unknown
C13a. Start date: ___/___/____
__
__
C12d. Treatment reported by:
C14: Pre-Immigration treatment concerns?
Treatment documented on DS forms
Yes
No
Patient reported treatment completion at or before
If YES,
panel physician examination
Treatment duration too short
Both-documented on DS forms & patient reported
Incorrect treatment regimen
Unknown
Other, please specify:
C12e. Standard TB treatment regimen was administered?
Reset pre-immigration treatment
Yes
No
Unable to verify
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