Tuberculosis Control Program - Contact Investigation Worksheet

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5
STATE OF CT TUBERCULOSIS CONTROL PROGRAM
CONTACT INVESTIGATION WORKSHEET
TB
Voice: (860) 509-7722
Fax:: (860) 509-7743
410 Capitol Avenue, MS #11TUB, P.O. Box 340308, Hartford, CT 06134-0308
:
#
:
TUBERCULOSIS EPIDEMIOLOGIST
STATE CASE
INTERVIEWER
:
FACILITY
:
CASE INFORMATION
(
,
,
)___________________________________________________________
:__________________________
NAME
LAST
FIRST
MI
DOB
:_________________________________
DATE INTERVIEW INITIATED
:_______________________
:
_____/_____/______
_____/_____/______
SITE OF DISEASE
INFECTIOUS PERIOD
START DATE
END DATE
:__________________________________________________
PHONE
:
:
:
EXPOSURE SETTING CODES
RISK FACTOR CODES FOR CONTACTS
REPORT AND DATE
[01]
[05]
/
[09]
[
]
< 5
HOUSEHOLD
SCHOOL
DAY CARE
WORKSITE
A
AGE
:
____/____/_____
DATE SENT
[02]
-
/
/
[06]
[10]
NON
HOUSEHOLD
FRIENDS
RELATIVES
NURSING HOME
UNKNOWN
[
]
B
IMMUNOCOMPROMISED
:
SENT TO
[
]
/
[03]
/
[07]
[11]
C
CXR CONSISTENT W
INACTIVE TB
RESTAURANT
BAR
SHELTER
OTHER
[
]
:
OTHER MEDICAL RISK
D
DATE FINAL REPORT REC
D
[04]
[08]
/
:___________________
____/____/_____
CORRECTIONAL FACILITY
HOSPITAL
ACUTE CARE
SPECIFY
<8
/
>8
/
EXPOSURE
WEEKS TST
QFT
WEEKS TST
QFT
CXR
TREATMENT
PROVIDER
:
CONTACT INFORMATION
:_____/______/_______
DATE
:
:
CODES
DATE STARTED
TST
QFT
TST
QFT
:____________________
:_____________________________
NAME
FIRST NAME
_____/_____/______
NORMAL
:
:
DATE
DATE
:______________________________
LAST NAME
:
-
DATE STOPPED
ABNORMAL
CONSISTENT
:_________________
ADDRESS
_____/_____/______
:________________________________
_____/_____/______
_____/_____/______
WITH INACTIVE TB
ADDRESS
:
REGIMEN
-
_________________________
ABNORMAL
CONSISTENT
________________________________
:
:
TST INDURATION
TST INDURATION
INH
RIF
RISK FACTOR
WITH TB DISEASE
:__________________________________
:
PHONE
CODES
_________
OTHER
_______________
_______________
_________________________
MM
MM
:
HIV TEST DATE
:
:
QFT RESULT
QFT RESULT
NO TREATMENT
_____/_____/______
: _____/_____/_______
:__________
DOB
GENDER
POSITIVE
POSITIVE
:___________________
PHONE
:
REASON NOT TREATED
:
NEGATIVE
NEGATIVE
POS
NEG
RESULTS
:_____________
:_____________
INDETERMINATE
INDETERMINATE
RACE
ETHNICITY
INDETERMINATE
<8
/
>8
/
EXPOSURE
WEEKS TST
QFT
WEEKS TST
QFT
CXR
TREATMENT
PROVIDER
:
CONTACT INFORMATION
:_____/______/_______
DATE
:
:
CODES
DATE STARTED
TST
QFT
TST
QFT
:____________________
NAME
:_____________________________
FIRST NAME
_____/_____/______
NORMAL
:
:
DATE
DATE
:______________________________
LAST NAME
:
-
DATE STOPPED
ABNORMAL
CONSISTENT
:_________________
ADDRESS
_____/_____/______
:________________________________
_____/_____/______
_____/_____/______
WITH INACTIVE TB
ADDRESS
:
REGIMEN
-
_________________________
ABNORMAL
CONSISTENT
________________________________
:
:
TST INDURATION
TST INDURATION
INH
RIF
RISK FACTOR
WITH TB DISEASE
:__________________________________
PHONE
:
CODES
_________
_______________
_______________
OTHER
_________________________
:
MM
MM
HIV TEST DATE
:
:
QFT RESULT
QFT RESULT
NO TREATMENT
_____/_____/______
: _____/_____/_______
:__________
DOB
GENDER
POSITIVE
POSITIVE
:___________________
:
PHONE
REASON NOT TREATED
:
NEGATIVE
NEGATIVE
RESULTS
POS
NEG
INDETERMINATE
INDETERMINATE
:_____________
:_____________
RACE
ETHNICITY
INDETERMINATE
<8
/
>8
/
EXPOSURE
WEEKS TST
QFT
WEEKS TST
QFT
CXR
TREATMENT
PROVIDER
:
CONTACT INFORMATION
:_____/______/_______
DATE
:
:
CODES
DATE STARTED
TST
QFT
TST
QFT
:____________________
NAME
:_____________________________
FIRST NAME
_____/_____/______
NORMAL
:
:
DATE
DATE
:______________________________
LAST NAME
:
-
DATE STOPPED
ABNORMAL
CONSISTENT
:_________________
ADDRESS
_____/_____/______
:________________________________
_____/_____/______
_____/_____/______
WITH INACTIVE TB
ADDRESS
:
REGIMEN
-
_________________________
ABNORMAL
CONSISTENT
________________________________
:
:
TST INDURATION
TST INDURATION
INH
RIF
RISK FACTOR
WITH TB DISEASE
:__________________________________
:
PHONE
CODES
_________
OTHER
_______________
_______________
_________________________
MM
MM
:
HIV TEST DATE
:
:
QFT RESULT
QFT RESULT
NO TREATMENT
_____/_____/______
: _____/_____/_______
:__________
DOB
GENDER
POSITIVE
POSITIVE
:___________________
PHONE
:
REASON NOT TREATED
:
NEGATIVE
NEGATIVE
POS
NEG
RESULTS
:_____________
:_____________
INDETERMINATE
INDETERMINATE
RACE
ETHNICITY
INDETERMINATE
1/2010
REVISED

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