Tuberculosis Disease Form
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1
2REPORT AND DATE (sent to State)
Local Health Department
Tuberculosis Disease
____/____/____
Initial
____/____/____
Treating Physician(s)______________________________
Verification
Case Manager_______________________________________________
_______________________________
____/____/____
Phone
Closure
CASE IDENTIFICATION
SOURCES OF REPORT
Last Name_____________________________________________ First Name_____________________________________ MI__________
Lab
Infection control
Physician
_______________
Phone(s) ________________________________________________________________________________________________________
Name ____________________________
Address _________________________________________________________________________________________________________
street
city
zip
___/____/____
Reported to LHD on
date of first report
Name of institution, if applicable (e.g. correctional facility, homeless shelter, nursing home) __________________________________________
Reported at death?
Yes
No
DEMOGRAPHICS
SEX
DATE OF BIRTH
RACE (self-identified; select all that apply)
HISPANIC
COUNTRY OF BIRTH
____/____/____
Male
White
American Indian/Alaskan Native
Yes
US
US Territory_____________
Female
Black
Asian _________________________________
No
Other________________________
Unknown
Hawaiian/Pac Islander____________________
Unknown
____/______
Latin American Indigenous________________________________
Date of entry to US
IMMIGRATION STATUS
At entry
Current
FOR PEDIATRIC TB (age <15)
PRIMARY OCCUPATION IN LAST 12 MONTHS
US born/NA
Lived outside US>2 months?
Health care worker
Other employment___________________
Immigrant visa
Yes
No
Unk
Correctional worker
Unemployed
Student visa
Migrant worker
Retired
Tourist visa
If yes, where:______________
Not seeking employment (eg student, disabled, homemaker)
Employment visa
_________________________
If not seeking, reason: __________________________________________
Family/Fiance visa
Worksite:
Refugee
Countries of birth of guardians:
Asylee/Parolee
________________________
HEALTH INSURANCE?
Yes
No
Other
Other __________________
________________________
Unknown ________________
If yes, list health plan:_______________________________________________
BASIS OF DIAGNOSIS
____/____/____
Medical care for symptoms first sought on
SITE OF DISEASE (check all that apply)
SYMPTOMATIC?
Pulmonary
Yes
No
Unk
Where?_____________________________
Pleural
____/____/____
If yes , ONSET on
Lymphatic
If patient did not seek care for TB symptoms, primary reason for evaluation:
Cervical
SYMPTOMS:
Contact investigation
Intrathoracic
Cough (duration _______)
Yes
No
Unk
Targeted testing
Axillary
Hemoptysis
Yes
No
Unk
Employment/Administrative screening
HCW?
Yes
No
Unk
Other lymph______________
Fever
Yes
No
Unk
Immigration exam
Other __________________
Night sweats
Yes
No
Unk
Incidental abnormal CXR/CT
Weight loss of _____lbs
Yes
No
Unk
Incidental lab result
____________________
Yes
No
Unk
Other___________________________________
TST AT DIAGNOSIS
QFT AT DIAGNOSIS
PRIOR TST/QFT
CHEST IMAGING AT DIAGNOSIS (Attach copies of chest x-rays and CT reports)
____/____/____
____/____/____
____/____/____
____/____/____
____/____/____
X-RAY
CT
Pos______ mm
Pos
Pos______ mm
Negative for TB
Negative for TB
Neg______ mm
Neg
Neg _____ mm
Abnormal non-cavitary, non-miliary
Abnormal, non-cavitary, non-miliary
Not Done
Indeterminate
Not Done
Abnormal, cavitary
Abnormal, miliary
Abnormal, cavitary
Abnormal, miliary
Not Done
Documented?_____
Not done
Not done
BACTERIOLOGY
Source of Specimen*
Date Collected
AFB Smear
NAAT/PCR
Culture/DNA Probe
Pathology Notes
Lab Name (If not OSPHL submit copies of labs)
4+ 3+ 2+ 1+ Neg
Pos Neg NA Pend
Pos Neg Pend
________________
____/____/____
________________
______________________________
4+ 3+ 2+ 1+ Neg
Pos Neg NA Pend
Pos Neg Pend
________________
____/____/____
________________
______________________________
4+ 3+ 2+ 1+ Neg
Pos Neg NA Pend
Pos Neg Pend
________________
____/____/____
________________
______________________________
4+ 3+ 2+ 1+ Neg
Pos Neg NA Pend
Pos Neg Pend
________________
____/____/____
________________
______________________________
*Please indicate results of diagnostic specimens (e.g. include the first positive AFB smear and first positive MTB culture)
Revised 10/31/2013
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