Report Of Sentinel Event Form - A/b Tuberculosis Notification
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2A/B Tuberculosis Notification
Report of Sentinel Event
Please use this form to report any of the following sentinel events identified in an immigrant arriving with a
Class A/B notification. Check all that apply:
Presence of acid-fast bacilli on examination in the United States (U.S.) with culture confirmation
of M.tb.
Identification of multidrug-resistant TB (MDR-TB) on evaluation of a newly arrived patient with
Class A/B notification
Sub-optimal treatment regimen prior to entering the U.S.
Significant discrepancies between the U.S. health department and the overseas examination or
treatment history
Patients who underwent overseas screening and did not receive a TB classification, but were
diagnosed with TB disease within 6 months of arrival in the U.S.
Other (Please describe):
_____________________________________________________________________________
_____________________________________________________________________________
Statement of Problem:
____________________________________________________________________________________
____________________________________________________________________________________
Patient Information
Patient’s Full Name: ______________________________
Country of origin: ________________
Alien Number: __ __-__ __ __-__ __ __
DOB: __ __/__ __/__ __ Date of U.S Entry: __ __/__ __/__ __
B classification:
B1
B2
B other TB
No B class
Type of arriver:
Immigrant
Refugee
Other
Contact Information
Your Name: ______________________________ Title: ________________________________
Phone Number: (__ __ __) __ __ __ - __ __ __ __
Email: ______________________________
Jurisdiction: ______________________________ Date: __ __/__ __/__ __
Please attach results of the overseas and U.S. medical examinations, including any relevant worksheets.
Check all items you are including:
Results of OVERSEAS medical examination:
Results of U.S. medical examination:
□
□
Patient hospital records
Medical Examination for Immigrant or Refugee Applicant (DS-2053)
□
□
Patient clinical progress notes
Medical Examination and Physical Examination Worksheet (DS-3026)
□
□
U.S. radiology reports
Chest X-ray and Classification Worksheet (DS-3024)
□
□
U.S. laboratory results
CDC 75.17 or Pre-Departure TB Classification Worksheet
□
□
U.S. local refugee health evaluation record
Additional overseas radiology reports
□
Additional overseas laboratory reports
□
Overseas hospital records
Phil Lowenthal, MPH
Please mail completed form and related documents to:
TB Control Branch, CDHS
850 Marina Bay Pkwy.
Questions? Call (510) 620-3045
nd
P-building, 2
floor
Richmond, CA 94804
Instructions for Reporting Sentinel Events in Class A/B Notifications
Tuberculosis Control Branch/California Department of Health Services
7/12/06 Ver. 2
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Parent category: Medical