TB Medical History Abstraction Form - School of Nursing
TB Medical History Abstraction Form - School of Nursing
TB Medical History Abstraction Form - School of Nursing
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__________________<br />
Contact Investigation Review Date <strong>of</strong> chart review ___/___/___<br />
Name <strong>of</strong> chart reviewer___________<br />
1) Case name:______________________________<br />
Alias?_______________________________<br />
Estimated period if infectiousness: Start ___/___/___ End___/___/___<br />
Address_____________________________<br />
City/state____________________________<br />
2) Was a contact investigation performed? Yes No Unknown<br />
If not, reason not performed___________________________________________<br />
3) Who performed the contact investigation?<br />
Name <strong>of</strong> organization________________________________________________<br />
4) How long has case lived at above address? Is any information known about prior<br />
places <strong>of</strong> residence (particularly reservations)?<br />
5) Please list all the names <strong>of</strong> contacts identified during the investigation and general<br />
results <strong>of</strong> their evaluations in the table on the following page:
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