Latent Tuberculosis Infection & Disease Report Form

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LATENT TUBERCULOSIS INFECTION & DISEASE REPORT
JOHNSON COUNTY HEALTH DEPARTMENT
DISEASE CONTAINMENT PROGRAM
6000 LAMAR SUITE 140, MISSION KS 66202
PHONE: 913-826-1303 FAX: 913-826-1300
___________________________________________________________________
_____ /_____ /_______
Patient’s Name:
Date of Birth:
Last
First
Middle
Month
Day
Year
Address: ______________________________________________________________________________________________________________________________
City: _____________________________________________
State: _______
Zip: ____________ Home Phone: ____________________________
Place of Employment: ______________________________________________________
Cell Phone: ____________________________
Race:
White
Black/African American
Place of Birth:
USA
American Indian/Alaskan Native
Asian
Other: (specify) ___________________________________________
Native Hawiian/Pacific Islander
Not Specified
Arrived In The US: _____ /_____ /_______
Ethnicity:
Gender:
Hispanic/Latino
Not Hispanic/Latino
Unknown
Male
Female
Reason For Test
Symptomatic
Employment
School
INS/Refugee
Group Home
Detention/Correctional Facility
:
(circle all that apply)
Current TST Placed:
_____ /_____ / _______
TST Read: _____ / _____ / _______
Induration: ________mm
Previous TST Placed: _____ / _____ / _______
TST Read: _____ / _____ / _______
Induration: ________mm
5 mm or more
10 mm or more
15 mm or more
___HIV Infection
___Recent Arrivals From High Prevalence Countries
___No Known Risk Factors
___Close Contact To An Active TB Case
___Injection Drug User
___Organ Transplant
___Residents & Employees of High-risk Congregate Setting
___Fibrotic Changes On CXR Consistent With Old TB
___Mycobaceriology Laboratory Personnel
___Other Immunosuppressed Clients
___Persons With Clinical Conditions That Make Them High-risk *
___Children <4 Yrs of Age, or Children & Adolescents
Exposed to Adults in High-risk Categories
*Usually Healthcare Workers Are Considered Positive at 10 mm Induration.
*Medical Conditions That Increase the Risk of TB Include: Diabetes, Silicosis, End Stage Renal Disease, Corticosteroid Therapy, Immunosuppressive Therapy,
Hematologic & Reticuloendothelial Diseases, Cancer of the Head & Neck, Chronic Malabsorption, Intestinal Bypass or Gastrectomy.
IGRA (T-Spot/Quantiferon Gold):
Positive
Negative
**Attach Lab Results**
Chest X-Ray: _____ /_ ____ / ______
Results: Normal
Abnormal
Unknown
**Attach Radiologic Interpretation**
Symptoms:
Cough
Fever
Night Sweats
Hemoptysis
Weight Loss
Fatigue
Chest Pain
Lymphadenopathy
Recent Contact To Active TB Case – Name of Case: _______________________________________________________________________________
Form Completed By: ____________________________________________________________________________
Date: _____ / _____ /_______
Healthcare Facility: ____________________________________________________________________
Phone: __________________________________
**Active Disease Tuberculosis: A Telephone Report Is Required By Law Within Four Hours of Suspect or Confirmed Cases
Revised 9/2010, 4/12

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