Alaska Tuberculosis Program Manual - Epidemiology - State of Alaska

CONTACT
Name:
Tuberculosis Contact Investigation Form—Continuation Page
Index Case Name: ___________________________________________
DOB: / / M F Relation to Case
Address: Race: White
Asian
AN/AI Black
PI Unknown
Dates of
Exposure:
Start: / / End: / /
City, State, Zip: Phone: ( ) / Priority* High Medium Low
Prior Positive TST No Yes Date: / / Result: mm IGRA Date: / / Negative Positive Equivocal
Initial TST Date: / / Result: mm Follow-up TST Date: / / Result: mm
Symptom
Screening
&
Result
Treatment
History
Date: / / Cough
Night Sweats
Asymptomatic
Symptomatic
LTBI
TB
None
Hemoptysis
Weight Loss
Other:
Start: / /
Stop: / /
Chest X-ray Date: / /
Sputum
Smears
Reason for
Ending
Treatment
Rev 8/11
Normal
Abnormal Abnormality:
Date: / / Date: / / Date: / /
Negative Positive Negative Positive Negative Positive
Completed
Contraindicated
Toxicity
Self-stopped
Refused
Lost
COMMENTS: Follow-Up
Follow-Up Complete: / /
CONTACT
Name:
DOB: / / M F Relation to Case
Moved
Died
Other
Lost to Follow Up: / /
Address: Race: White
Asian
AN/AI Black
PI Unknown
Dates of
Exposure:
Start: / / End: / /
City, State, Zip: Phone: ( ) / Priority* High Medium Low
Prior Positive TST No Yes Date: / / Result: mm IGRA Date: / / Negative Positive Equivocal
Initial TST Date: / / Result: mm Follow-up TST Date: / / Result: mm
Symptom
Screening
&
Result
Treatment
History
Date: / /
Asymptomatic
Symptomatic
LTBI
TB
None
Cough
Night Sweats
Hemoptysis
Weight Loss
Other:
Start: / /
Stop: / /
Chest X-ray Date: / /
Sputum
Smears
Reason for
Ending
Treatment
Normal
Abnormal Abnormality:
Date: / / Date: / / Date: / /
Negative Positive Negative Positive Negative Positive
Completed
Contraindicated
Toxicity
Self-stopped
Refused
Lost
COMMENTS: Follow-Up
Follow-Up Complete: / /
Lost to Follow Up: / /
Provider Signature: ___________________________________ Clinic Name: ___________________________________________ Date: ______ / _______ / ______
Moved
Died
Other
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