Form Oha 8155 - Treatment Of Ltbi Data
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1
2PUBLIC HEALTH DIVISION
HIV-STD-TB Programs/Oregon TB Control
Health department or ODOC location:
Name: (last)
(fi rst)
(M.I.)
DOB:
ID number:
Address:
Phone number:
Race (specify):
Hispanic:
Homeless in past year?
Gender:
Yes
No
Yes
No
Male Female
Country of origin:
USA
Other:________________________________
Date arrived: ________________
EVALUATION
Tuberculin skin test:
Date: ________________
Result: _______________ mm
Interpretation:
Positive
Negative
IGRA (QuantiFERON/T Spot):
Date: __________________
Result: __________________
Chest x-ray:
Date: ________________
Results:
Abnormal-not active TB
Normal
Diagnosis:
Latent TB infection
Previous LTBI Tx (date): ________________
Other:________________
Reason for testing (risk factors):
Contact
Medical (converter, HIV+, IVDU, <5 years old, diabetes, silicosis, chronic renal failure, gastrectomy, immunosuppressive therapy, etc.)
Population (high prevalence country, incarcerated, health care facility, nursing home, homeless shelter, etc.)
No known risk factors (NOTE: This form is NOT needed for contacts to cases. Complete contact investigation form or Orpheus.)
LTBI TREATMENT
Treatment start date: __________________
Regimen:
INH daily 6 months (180 doses in 9 months)
INH and Rifapentine DOT 12 once weekly doses
INH daily 9 months (270 doses in 12 months)
INH bi-weekly DOT 6 months (52 doses in 9 months)
Rifampin daily 4 months (120 doses in 6 months)
INH bi-weekly DOT 9 months (76 doses in 12 months)
CLOSED
Date closed:___________________
Reason closed:
Completed treatment
Client stopped on own
Active TB diagnosed
Lost to follow-up
Provider decision: Toxicity
Died
Therapy: DOT Yes No
Moved: Transferred care
Provider decision: Other
Both, self and observed
to:______________________
Specify:__________________
Moved: Follow-up unknown
When closed section is completed, fax 971-673-0178 or mail copy of this form to:
TB Control
800 NE Oregon Street, Suite 1105
Portland, Oregon 97232
OHA 8155 (03/12)
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