Form Dhhs-1247 - Mycobacteriology (Tb) - N.c. Department Of Health And Human Services
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1
2N.C. Department of Health and Human Services
1. Last Name
First Name
MI
DO NOT WRITE IN THIS SPACE
State Laboratory of Public Health
LABORATORY NUMBER
4312 District Drive • P.O. Box 28047
2. Patient Number
Raleigh, NC 27611-8047
(Soc. Security No.)
4. Date of Birth
3. Address
________________________________
________________________________
...........................................................
Month
Day
Year
Zip
Code
MYCOBACTERIOLOGY (TB)
5. Race
1. White
2. Black
3. American Indian
4. Asian
PLEASE GIVE ALL INFORMATION REQUESTED
5. Native Hawaiian/Pacifi c Islander
6. Unknown
6. Hispanic or Latino Origin:
1. Yes
2. No
3. Unknown
DATE COLLECTED
PREVIOUSLY DIAGNOSED??
M. TUBERCULOSIS
OTHER MYCOBACTERIA (SPECIFY)
M
D
Y
7. Sex
1. Male
2. Female
8. Co. of Residence
Yes
No
DRUG THERAPY
9. Medicaid Client
Yes
NONE
INH
SM
PZA
EMB
RIF
OTHER___________________
If yes, enter #
No
SPECIMEN TYPE
CLINICAL
REFERENCE
DATE DRUG THERAPY STARTED _______________________
Federal Tax No.: _______________________________________
SOURCE OF SPECIMEN
Send Report To:
NATURAL SPUTUM
INDUCED SPUTUM
BRONCH. WASH
URINE
OTHER ________________________________
IS PATIENT ON RESPIRATORY ISOLATION?
Yes
No
RISK FACTORS:
HIV Positive
Cough > 2 Weeks
Immigrant from High-incidence Country
Direct Contact to TB Case
IV Drug User
Other ________________________________
SIGNS/SYMPTOMS:
PHONE NUMBER: _____________________________________________________
Cough
Fever, Chills, Night Sweats
Signifi cant Weight Loss
Hemoptysis
DIAGNOSIS CODE (ICD-9): ______________________________________________
Other ________________________________
LABORATORY USE — DO NOT WRITE BELOW THIS LINE
MICROSCOPIC REPORT
ACID FAST BACILLI
Found
1+
2+
3+
4+
Not Found
CULTURE REPORT
CONVENTIONAL SUSCEPTIBILITY TEST
SPECIMEN UNSATISFACTORY:
No Growth
Contaminated
DRUGS
Growth* at Dilutions
BROKEN/LEAKED IN TRANSIT
IDENTIFICATION
Microgr./mL
SPECIMEN TOO OLD
M. tuberculosis Complex
_____________
Control
NO SPECIMEN
INH
0.2
Photochromogen
Non-Photochromogen
SPECIMEN UNLABELED
INH
1.0
M. kansasii
MAIS
NONVIABLE
SM
2.0
M. marinum
MAI complex
OTHER
RIF
1.0
____________________________________
_____________
M. terrae complex
EMB
5.0
M. xenopi
____________________________________
EMB
10.0
Scotochromogen
M. triviale
PAS
2.0
M. scrofulaceum
Unclassifi ed
KM
6.0
M. gordonae
______________
THA
5.0
M. szulgai
CAP
10.0
Unclassifi ed
Rapid Growers
CS
30.0
_____________
M. fortuitum gr.
CIP
2.0
M. chelonae/
Nocardia sp.
abscessus gr.
Rhodococcus/
Unclassifi ed
*Number of Colonies
Gordona sp.
______________
Tsukamurella sp.
C = Colonies
COMMENTS:
POSITIVE
for MTBC by RT-PCR
Tech _____________ Date ______________
Refer to Culture # __________ for susceptibility results.
NEGATIVE
for MTBC by RT-PCR
Culture Colony Count: _____________
Tech _____________ Date ______________
DHHS 1247 (Revised 08/13)
Laboratory (Review 08/16)
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