Edn Tb Follow-Up Worksheet Page 2
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EDN TB Follow-Up Worksheet (Cont)
Last reviewed: 6/21/2013
Reset US lab
C15. U.S. Microscopy/Bacteriology*
Sputa collected in U.S.?
No
Yes
*Covers all results regardless of sputa collection method.
#
Date Collected
AFB Smear
Sputum Culture
Drug Susceptibility Testing
MDR-TB
NTM
MTB Complex
Mono-RIF
Positive
Negative
1
___/___/_____
Contaminated
Negative
Mono-INH
Other DR
Not Done
Unknown
_
No DR
Not Done
Unknown
Not Done
MDR-TB
NTM
MTB Complex
Mono-RIF
Positive
Negative
___/___/_____
2
Contaminated
Negative
Mono-INH
Other DR
_
Not Done
Unknown
Not Done
Unknown
No DR
Not Done
MDR-TB
NTM
MTB Complex
Mono-RIF
Positive
Negative
3
___/___/_____
Contaminated
Negative
Mono-INH
Other DR
_
Not Done
Unknown
Not Done
Unknown
No DR
Not Done
D. Evaluation Disposition
D1. Evaluation disposition date:
___/____/______
D2. Evaluation disposition:
Completed evaluation
Initiated Evaluation / Not completed
Did not initate evaluation
If evaluation was completed, was
If evaluation was NOT completed, why not?
treatment recommended?
Moved within U.S., transferred to:
Not Located
Yes
No
Lost to Follow-Up
Moved outside U.S.
LTBI
Died
Refused Evaluation
Active TB
Unknown
Other, specify
D3. Diagnosis
Class 0 - No TB exposure, not infected
Class 1 - TB exposure, no evidence of infection
Reset Eval Disposition
Class 2 - TB infection, no disease
Class 3 - TB, TB disease
Pulmonary
Extra-pulmonary
Both sites
Class 4 - TB, inactive disease
RVCT Reported
D5. RVCT #:
RVCT # unknown
D
If diagnosed with TB disease,
4.
E. U.S. Treatment
E1. U.S. treatment initiated:
Yes
No
Unknown
If NO, specify the reason:
Patient declined against medical advice
Lost to follow-up
Moved within U.S, tranferred to:
Died
Moved outside the U.S.
Other (specify)
Unknown
TB disease
LTBI
If YES:
E2. Treatment start date:
___/____/______
E3. U.S. treatment completed:
Yes
No
Unknown
If NO, specify the reason:
Adverse effect
Patient stopped against medical advice
Lost to follow-up
Moved within U.S, tranferred to:
Provider decision
Moved outside the U.S.
Died
Unknown
Other (specify)
If treatment was completed,
E4. Treatment completion date:
___/____/______
Reset US Treatment
If treatment was iniated but NOT completed,
E5. Treatment end date:
___/____/______
F. Comments
G. Screen Site Information
Provider’s Name:
Clinic Name:
Telephone Number:
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