Case Contact Roster Form (Ccr) Page 2
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1
2CASE CONTACT ROSTER
INDEX CASE/SUSPECT INFORMATION:
Name:
DOB:____/_____/________
LIST OF CONTACTS TO THE INDEX CASE / SUSPECT
LTBI/
LTBI/
DOB
Re-
LTBI/ Window
Documented
1
TST/IGRA
2nd TST/IGRA
st
Final
Address,
Window
Window
lation
Country
CXR
prior TST/IGRA
date
date
Name
LHJ
Priority
ATS
Comments
1
Start date
Recom-
Rx
of Birth
Result
to
2
Age
Phone number
Class
4
If yes, Result
Result
Result
mended
Status
3
case
End date
____/____/___
____/____/___
High
Yes / No
___/___/___
____/____/____
Medium
mm
mm
mm
Yes / No
Low
Pos / Neg / Indet.
Pos / Neg / Indet.
Pos / Neg / Indet.
____/____/____
____/____/___
____/____/___
High
Yes / No
___/___/___
____/____/____
Medium
mm
mm
mm
Yes / No
Low
Pos / Neg / Indet.
Pos / Neg / Indet.
Pos / Neg / Indet.
____/____/____
____/___/___
____/____/___
High
Yes / No
___/___/___
____/____/____
Medium
mm
mm
mm
Yes / No
Low
Pos / Neg / Indet.
Pos / Neg / Indet.
Pos / Neg / Indet.
____/____/____
____/____/___
____/____/___
High
Yes / No
___/___/___
____/____/____
Medium
mm
mm
mm
Yes / No
Low
Pos / Neg / Indet.
Pos / Neg / Indet.
Pos / Neg / Indet.
____/____/____
____/____/___
____/____/___
High
Yes / No
___/___/___
____/____/____
Medium
mm
mm
mm
Yes / No
Low
Pos / Neg / Indet.
Pos / Neg / Indet.
Pos / Neg / Indet.
____/____/____
____/____/___
____/____/___
High
Yes / No
___/___/___
____/____/____
Medium
mm
mm
mm
Yes / No
Low
Pos / Neg / Indet.
Pos / Neg / Indet.
Pos / Neg / Indet.
____/____/____
____/____/___
____/____/___
High
Yes / No
___/___/___
____/____/____
Medium
mm
mm
mm
Yes / No
Low
Pos / Neg / Indet.
Pos / Neg / Indet.
Pos / Neg / Indet.
____/____/____
____/____/___
____/____/___
High
Yes / No
___/___/___
____/____/____
Medium
mm
mm
mm
Yes / No
Low
Pos / Neg / Indet.
Pos / Neg / Indet.
Pos / Neg / Indet.
____/____/____
LHJ: Indicate the local health jurisdiction conducting the contact investigation
1
Code for CXR Result: 1 – Normal
2 – Abnormal, cavitary
3 – Abnormal, non-cavitary consistent with TB
4 – Abnormal, non-cavitary NOT consistent with TB
2
Code for Rx Status:
1 - LTBI Treatment Complete
3 - Contact chose to stop
5 - MD chose to stop
7 - Contact moved (f/u unknown)
9 - Died
11 - Other
3
2 - Final TST negative, window prophylaxis ended
4 - Adverse Reaction-contact chose to stop
6 - Adverse Reaction-MD advised to stop
8 - Lost
10 - Active TB developed
Code for Final ATS Class:
1-TB exposure, not infected
2-Latent TB infection (LTBI), no TB disease
3-Active TB disease
4-Old TB disease
4
CCR August 2008
Page ______ out of ______
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