TB Medical History Abstraction Form - School of Nursing

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__________________ Contact Investigation Review Date of chart review ___/___/___ Name of chart reviewer___________ 1) Case name:______________________________ Alias?_______________________________ Estimated period if infectiousness: Start ___/___/___ End___/___/___ Address_____________________________ City/state____________________________ 2) Was a contact investigation performed? Yes No Unknown If not, reason not performed___________________________________________ 3) Who performed the contact investigation? Name of organization________________________________________________ 4) How long has case lived at above address? Is any information known about prior places of residence (particularly reservations)? 5) Please list all the names of contacts identified during the investigation and general results of their evaluations in the table on the following page:
Name (Last, First MI) DOB (age) Sex Relation City/state of residence HML? Evaluation Result (i.e. dates and results of TSTs/CXRs, incomplete eval., lost to follow up) TST converter?
Page 1 and 2: TB Medical History Abstraction Form
Page 3 and 4: Site of Disease: Pulmonary Pleura
Page 5: Relationship_______________________
Page 9: 12) Any record in the past 2 years

TB Medical History Abstraction Form - School of Nursing

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