Form Dhhs 1662 - Nursing Record Of Tuberculosis Contacts Form - U.c. Department Of Health And Human Services

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1. Last Name
First Name
MI
N.C. Department of Health and Human Services
2. Patient Number
Division of Public Health
Epidemiology Section • TB Control Program
3. Date of
Birth
Month
Day
Year
Nursing Record of
□
□
4. Race
1. American Indian/Alaska Native
2. Asian
□
□
3. Black/African American
4. Native Hawaiian/
Tuberculosis Contacts
□
□
Other Pacifi c Islander
5. White
6. Unknown
□
□
□
Ethnicity: Hispanic or Latino Origin?
Yes
No
Unknown
□
□
5. Gender
1. Male
2. Female
7. Date Case Reported to Health Department _____/_____/_____
6. County of Residence
□
□
□
□
□
□
□
8. Contact To:
Pulmonary TB Case: Smear
Pos
Neg
Not Done Culture
Pos
Neg
Not Done Specimen Source __________
□
Suspect, Not TB After Evaluation
Contact Information
Tests & Exposure
Treatment
Name:
TST # 1 Date placed: _______________
Treatment plan: ___ INH ___ RIF
mm reading:
___ Other _____________________
IGRA date: _________ result: __________
___ window period prophylaxis
DOB:
Age:
TST # 2 Date placed: _______________
mm reading:
Race:
Gender:
IGRA date: _________ result: __________
Address:
TST # 3 Date placed: _______________
Declined treatment: ___ yes ___ no
mm reading:
Date started: ____________________
Date completed: _________________
IGRA date: _________ result: __________
If treatment not completed, why not:
County of Residence:
HIV: ___ neg. ___ pos. ___ declined
___ TB disease developed
Date of HIV test:
___ adverse reaction
___ died
Country of Birth:
Date of CXR: _______________________
___ patient stopped
CXR result:
If not U.S., date of entry:
___ lost to follow-up
Exposure site name:
___ provider decision
Hours of exposure:
Previous history of TB: ___ yes ___ no
___ moved
Date identifi ed as a contact: ____________
If yes, date: __________________________
Priority level:
Previous history of LTBI: ___ yes ___ no
___ High ___ Medium ___ Low
Date of TST/IGRA ________ MM reading: _____
Comments:
Was treatment completed: ___ yes ___ no
Symptom screening done: ___ yes ___ no
Contact Information
Tests & Exposure
Treatment
Name:
TST # 1 Date placed: _______________
Treatment plan: ___ INH ___ RIF
mm reading:
___ Other _____________________
IGRA date: _________ result: __________
___ window period prophylaxis
DOB:
Age:
TST # 2 Date placed: _______________
mm reading:
Race:
Gender:
IGRA date: _________ result: __________
Address:
TST # 3 Date placed: _______________
Declined treatment: ___ yes ___ no
mm reading:
Date started: ____________________
Date completed: _________________
IGRA date: _________ result: __________
If treatment not completed, why not:
County of Residence:
HIV: ___ neg. ___ pos. ___ declined
___ TB disease developed
Date of HIV test:
___ adverse reaction
___ died
Country of Birth:
Date of CXR: _______________________
___ patient stopped
CXR result:
If not U.S., date of entry:
___ lost to follow-up
Exposure site name:
___ provider decision
Hours of exposure:
Previous history of TB: ___ yes ___ no
___ moved
Date identifi ed as a contact: ____________
If yes, date: __________________________
Priority level:
Previous history of LTBI: ___ yes ___ no
___ High ___ Medium ___ Low
Date of TST/IGRA ________ MM reading: _____
Comments:
Was treatment completed: ___ yes ___ no
Symptom screening done: ___ yes ___ no
→
DHHS 1662 (Revised 03/14)
TB Control (Review 03/17)

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