Case Contact Roster Form (Ccr)
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1
2CASE CONTACT ROSTER
INDEX CASE / SUSPECT INFORMATION
Case manager name:
Case/suspect out of jurisdiction
No
Yes, Jurisdiction
/
/
/
/
Initial interview date:
Follow-up interview date:
(1)
Last name
First name
MI
/
/
(2)
Date of birth
(3)
Patient number
(4)
State TB registry (RVCT) number
(5)
Gender
Female
Male
/
/
(6)
Date index case/suspect identified
(7)
Initial TB classification
TB 3
TB 5
(8)
Sputum smear
Positive
Negative
Not done
(9)
Sputum culture
Positive
Negative
Not done
(10) Other culture
Positive
Negative
Not done
Other culture source
(11) Site(s) of disease (check all that apply)
Pulmonary
Laryngeal
Pleural
Other, specify site(s):
(12) Chest x-ray result:
Normal
Abnormal, cavitary
Abnormal, non-cavitary consistent with TB
Abnormal, non-cavitary not consistent with TB
(13) Drug susceptibility
INH:
R
S
N/D
RIF:
R
S
N/D
EMB:
R
S
N/D
PZA:
R
S
N/D
SM:
R
S
N/D
Other drug:
R
S
Other drug:
R
S
/
/
/
/
(14) Period of infectiousness from
to
____/____/_______
(15) If the CI was discontinued or not initiated, specify why:
TB controller decision
Index case/suspect determined not to have active TB disease date
/
/
(16) Final TB classification
TB 0
TB 2
TB 3
TB 4
(17) Date the patient was verified as a TB case (count date)
(18) What is the patient’s primary language?
(19) What language was used to conduct the case interview?
(20) Contacts out of jurisdiction?
No
Yes, specify jurisdiction(s):
(21) Where did the index case/suspect typically spend time during their infectious period?
(e.g., school, work, place of worship, recreation/social, healthcare settings, homeless shelters, prison/jail, detox center, etc)
(a)
date:
(d)
date:
____/____/_______
____/____/_______
(b)
date:
(e)
date:
____/____/_______
____/____/_______
(c)
date:
(f)
date:
____/____/_______
____/____/_______
CCR August 2008
Page 1 out of ______
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