Interjurisdictional Tb Notification Follow-Up Form
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1Interjurisdictional TB Notification (IJN) Follow-Up Form
Date Follow-Up
Report Status
Follow-Up On
Form Sent
Return Follow-Up Form To:
Name
Phone
Fax
Address
City
State
Zip
Person Completing Form:
Name
Jurisdiction
Phone
Fax
Email
Referred Person’s Information:
Last Name
First Name
Middle Name
DOB
Sex
Hispanic
Race/Ethnicity
Country of Birth
Evaluation
Follow-Up Information:
Evaluation
Treatment
Outcome
If Active TB Disease:
Counting Jurisdiction
RVCT #
Results Attached: Please attach all applicable results
RVCT
TST
IGRA
Radiology
Smear(s)
NAAT
Culture(s)/Pathology
DST/Mutation
Submitted for
Other Lab
Gentype
Analysis
Genotyping
(specify)
Reason
Disposition:
Date of Disposition
Dispositioned
If Patient Moved:
Notified New Jurisdiction
New Address
City
County
Zip
State/Province/
Country
Phone
Region
Comments:
Note: This form contains confidential patient information. Please comply with HIPAA regulations when sending this form.
National Tuberculosis Nurse Coalition (NTNC)
National Tuberculosis Controllers Association (NTCA)
Revision: November 2014
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Parent category: Legal