Alaska Tuberculosis Program Manual - Epidemiology - State of Alaska

Latent Tuberculosis Infection (LTBI) Treatment Completion Report
Name:_________________________________________ DOB: _______________ Age: _____________
Street: ________________________________________________________________________________
State: ____________ Zip code: ___________ Date LTBI treatment started: ____/____/____
Please return form by: ____/____/____
SECTION 1: SECTION 2:
Date LTBI treatment completed: Regimen: Administered by:
____/____/____ 9 months INH DOT
6 months INH__________ Self/parent
4 months RIF___________
12 week INH / RPT
Other______________
SECTION 3:
Reason LTBI treatment was discontinued before completion:
a) Discontinued by physician due to adverse reaction. Date___/___/___
b) Discontinued on medical advice for reason other than adverse reaction. Date___/___/___
c) Discontinued by patient against medical advice. Date___/___/___
d) Patient lost to follow-up. Date___/___/___
Attempted outreach: letter(s) ______ phone call(s) _______
e) Patient moved.
New address: __________________________ Date___/___/___
__________________________
__________________________
f) Patient died Date___/___/___
g) Patient developed active tuberculosis.
Notes: ______________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
Return to:
Alaska TB Program
3601 C Street, Suite 540
Anchorage, AK 99503
FAX: 907-563-7868
Rev 11/12