Form Cdc 72.9c - Report Of Verified Case Of Tuberculosis printable pdf download

Patient’s Name _________________________________________________________

REPORT OF VERIFIED CASE

(Last)

(First)

(M.I.)

OF TUBERCULOSIS

Street Address _____________________________________________________________________________________ _______________

(Number, Street, City, State)

(ZIP CODE)

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR DISEASE CONTROL

REPORT OF VERIFIED CASE OF TUBERCULOSIS

AND PREVENTION (CDC)

ATLANTA, GEORGIA 30333

FORM APPROVED OMB NO. 0920-0026 Exp. Date 05/31/2011

Case Completion Report

(Follow Up Report – 2)

Year Counted

State

Case Number

City/County

Case Number

Submit this report for all cases in which the patient was alive at diagnosis.

41. Sputum Culture Conversion Documented (select one)

Yes

Unknown

If NO, enter reason for not documenting sputum culture conversion (select one):

If YES, enter date specimen collected for FIRST

consistently negative sputum culture:

No Follow-up

Patient Refused

Patient Lost to Follow-Up

Sputum Despite Induction

Month

Day

Year

Other Specify ____________________________________

No Follow-up Sputum and No Induction

Died

Unknown

42. Moved

Did the patient move during TB therapy? (select one)

Yes

If YES, moved to where (select all that apply):

In state, out of jurisdiction (enter city/county) Specify________________________________________ Specify________________________________________

Out of state (enter state)

Specify________________________________________ Specify________________________________________

Out of the U.S. (enter country)

Specify________________________________________ Specify________________________________________

If moved out of the U.S., transnational referral? (select one)

Yes

43. Date Therapy Stopped

44. Reason Therapy Stopped or Never Started (select one)

If DIED, indicate cause of death (select one):

Completed Therapy

Not TB

Month

Day

Year

Lost

Died

Related to TB disease

Unrelated to TB disease

Uncooperative or Refused

Other

Related to TB therapy

Unknown

Adverse Treatment Event

Unknown

45. Reason Therapy Extended >12 months (select all that apply)

Rifampin Resistance

Non-adherence

Clinically Indicated – other reasons

Other Specify _________________________________________

Adverse Drug Reaction

Failure

46. Type of Outpatient Health Care Provider (select all that apply)

Local/State Health Department (HD)

IHS, Tribal HD, or Tribal Corporation

Inpatient Care Only

Unknown

Private Outpatient

Institutional/Correctional

Other

Comments:

____________________________________________________________________________________________________________________________________________________________

Public reporting burden of this collection of information is estimated to average 35 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and main-

taining the data needed and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it

displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC,

Project Clearance Officer, 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0026). Do not send the completed form to this address.

Information contained on this form which would permit identification of any individual has been collected with a guarantee that it will be held in strict confidence, will be used only for surveillance purposes,

and will not be disclosed or released without the consent of the individual in accordance with Section 308(d) of the Public Health Service Act (42 U.S.C. 242m).

1st Copy

CDC 72.9C Rev 09/15/2008 CS121321

REPORT OF VERIFIED CASE OF TUBERCULOSIS

Follow Up Report -2 / Page 1 of 2