Tuberculosis Contact Investigation Transfer Form Page 2
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1
2Tuberculosis Contact Investigation -
REFERRING LHD
Transfer Form
Case Initials____________________________________
State Case#_______________________
Local Case#_______________________
CONTACT* INFORMATION - TRANSFER
≥ 8 week TST/QFT
Contact Risks
Symptoms <8 week TST/QFT
CXR
LTBI Treatment
Final Status***
High Risk of Infection
Low Risk of Infection
Yes
TST:
TST:
Date Started
Completed LTBI Tx
____/____/____ ____/____/____ ____/____/____
____/____/____
First Name _______________________________
Household
No risk
No
TB Disease
Last Name _______________________________
Age<5
Other low risk
TST mm________
TST mm________
Negative
Died
Address _________________________________
HIV/AIDS
___________
QFT:
QFT:
Abnormal consistent
Date Stopped
Refused
____/____/____ ___/____/____
_
____/____/____
Phone___________________________________
CXR c/w Inactive TB
with TB disease
Lost
Date of Birth ____/____/______
Congregate Setting
Result:____________
Result:____________
Abnormal consistent
Regimen:
Moved__________
Country of Birth______________ DOE ____/____
Exceeds Exposure Limits
with inactive TB
INH
Adverse Rxn to Tx
Date Last Exposed ____/____/____ or
ongoing
Other Medical Risk
Prior TST/QFT+__________
_________________
Rif
Other Provider
Other_______________
Prior TX_________________
_________________
Other_________
Decision ________
High Risk of Infection
Low Risk of Infection
Yes
TST:
TST:
Date Started
Completed LTBI Tx
____/____/____ ____/____/____ ____/____/____
____/____/____
First Name _______________________________
Household
No risk
No
TB Disease
Last Name _______________________________
Age<5
Other low risk
TST mm________
TST mm________
Negative
Died
Address _________________________________
HIV/AIDS
___________
QFT:
QFT:
Abnormal consistent
Date Stopped
Refused
____/____/____ ___/____/____
_
____/____/____
Phone___________________________________
CXR c/w Inactive TB
with TB disease
Lost
Date of Birth ____/____/______
Congregate Setting
Result:____________
Result:____________
Abnormal consistent
Regimen:
Moved__________
Country of Birth______________ DOE ____/____
Exceeds Exposure Limits
with inactive TB
INH
Adverse Rxn to Tx
Date Last Exposed
Date Last Exposed ____ ____ ____ or
/
/
/
/
o
r
ongoing
on o
g
ing
Oth M di l Ri k
Other Medical Risk
P i
P i TST/QFT+
r or TST/QFT+__________
_________________
Rif
Rif
Oth P
Other Provider
id
Other_______________
Prior TX_________________
_________________
Other_________
Decision ________
High Risk of Infection
Low Risk of Infection
Yes
TST:
TST:
Date Started
Completed LTBI Tx
____/____/____ ____/____/____ ____/____/____
____/____/____
First Name _______________________________
Household
No risk
No
TB Disease
Last Name _______________________________
Age<5
Other low risk
TST mm________
TST mm________
Negative
Died
Address _________________________________
HIV/AIDS
___________
QFT:
QFT:
Abnormal consistent
Date Stopped
Refused
____/____/____ ___/____/____
_
____/____/____
Phone___________________________________
CXR c/w Inactive TB
with TB disease
Lost
Date of Birth ____/____/______
Congregate Setting
Result:____________
Result:____________
Abnormal consistent
Regimen:
Moved__________
Country of Birth______________ DOE ____/____
Exceeds Exposure Limits
with inactive TB
INH
Adverse Rxn to Tx
Date Last Exposed ____/____/____ or
ongoing
Other Medical Risk
Prior TST/QFT+__________
_________________
Rif
Other Provider
Other_______________
Prior TX_________________
_________________
Other_________
Decision ________
High Risk of Infection
Low Risk of Infection
Yes
TST:
TST:
Date Started
Completed LTBI Tx
____/____/____ ____/____/____ ____/____/____
____/____/____
First Name _______________________________
Household
No risk
No
TB Disease
Last Name _______________________________
Age<5
Other low risk
TST mm________
TST mm________
Negative
Died
Address _________________________________
HIV/AIDS
___________
QFT:
QFT:
Abnormal consistent
Date Stopped
Refused
____/____/____ ___/____/____
_
____/____/____
Phone___________________________________
CXR c/w Inactive TB
with TB disease
Lost
Date of Birth ____/____/______
Congregate Setting
Result:____________
Result:____________
Abnormal consistent
Regimen:
Moved__________
Country of Birth______________ DOE ____/____
Exceeds Exposure Limits
with inactive TB
INH
Adverse Rxn to Tx
Date Last Exposed ____/____/____ or
ongoing
Other Medical Risk
Prior TST/QFT+__________
_________________
Rif
Other Provider
Other_______________
Prior TX_________________
_________________
Other_________
Decision ________
* A contact is a person whom the health department believes had significant exposure,and for whom enough identifying/contacting information is available.
Page _____ of _____
** Relative risk of infection depends on exposure and medical risk factors of the contact. For congregate setting exposures, contact the State for assistance in categorizing the contact's risk of infection.
Revised 4/14/2010
*** Complete for contacts not fully evaluated or contacts starting treatment
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