Form 3897 - Tuberculosis Registry
Download a blank fillable Form 3897 - Tuberculosis Registry in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form 3897 - Tuberculosis Registry with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1TUBERCULOSIS REGISTRY
For use of this form, see DA PAM 40-11; the proponent agency is OTSG.
AUTHORITY:
10 U.S.C. 3013, Secretary of the Army; 10 U.S.C. Chapter 55; Army Regulation 40-407.
To provide a means for case management and surveillance of Latent Tuberculosis Infection (LTBI).
PRINCIPAL PURPOSE:
In addition to those disclosures generally permitted under 5 U.S.C. 552a(b) of the Privacy Act, these records or information
ROUTINE USE(S):
contained therein may specifically be disclosed outside the DOD as a routine use pursuant to 5 U.S.C. 552a(b)(3) as
follows: The DoD 'Blanket Routine Uses' set forth at the beginning of the Army's compilation of systems of records notices
also apply to this system. NOTE: This system of records contains individually identifiable health information. The DoD
Health Information Privacy Regulation (DoD 6025.18-R) issued pursuant to the Health Insurance Portability and
Accountability Act of 1996, applies to most such health information. DoD 6025.18-R may place additional procedural
requirements on the uses and disclosures of such information beyond those found in the Privacy Act of 1974 or mentioned in
this system of records notice.
Mandatory. Mandatory reporting provides the information necessary for public health officials to protect the public's health by
DISCLOSURE:
tracking communicable disease and other conditions. Notification allows public health officials to treat persons already ill,
provide preventive therapies for individuals who came into contact with infectious agents, and investigate and halt outbreaks.
It also allows for assessment of broader patterns by historical trends or geographic clustering. Armed with this knowledge,
public health officials can take action by redirecting programs or developing new policies.
1. NAME
(Last, First, MI)
1
2
3
4
5
6
7
8
9
10
11
12
2. DATE OF BIRTH
3. STATUS
4. BRANCH
(YYYYMMDD)
ARMY
MARINE
AF
OTHER (Specify)
NAVY
AD
RET
DEP
5. SPONSOR
6. RANK
7. UNIT ADDRESS
8. DUTY PHONE
9. HOME ADDRESS
(Include Zip Code)
10. EMAIL ADDRESS
11. HOME PHONE
12. ACTIVE CASE
ADMITTED
ADMITTED DATE
DISCHARGE DATE
*ATS CODE
CONTACTS CHECKED
(YYYYMMDD)
(YYYYMMDD)
YES
NO
YES
NO
13. CONTACT
CONTACT OF
DATE CONTACT TERMINATED
(YYYYMMDD)
CLOSE
CASUAL
14. CONVERTER/REACTOR
SKIN TEST RESULTS
LAST NEGATIVE SKIN TEST
CONTACTS CHECKED
DATE
TYPE
SIZE
DATE
TYPE
(YYYYMMDD)
(YYYYMMDD)
YES
NO
15. DRUG REGIMEN
DATE STARTED
TYPE
DOSE
FREQUENCY
LENGTH OF THERAPY
(YYYYMMDD)
16. REPORTED TO STATE/LOCAL HEALTH DEPARTMENT (If yes, list name of State or Local Health Department and date reported.)
YES
NO
17. X-RAY FINDINGS
DATE
TEST RESULTS
DATE
NOTES
(YYYYMMDD)
(YYYYMMDD)
18. RETURN VISIT ACTIONS (Use pencil).
*American Thoracic Society standard diagnostic and therapeutic code.
DA FORM 3897, MAY 2009
PREVIOUS EDITIONS ARE OBSOLETE.
APD LC v1.00
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business