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Minnesota Department of Health
Tuberculosis Prevention and Control Program
625 Robert Street North
St. Paul, MN 55164-0975
TUBERCULOSIS CONTACT INVESTIGATION REPORT
INDEX CASE: MDH Case Number: County: Date Counted by MDH: _____/_____/_____
Name:______________________________________________________________________________
Last First
M.I.
Birth Date: _____/_____/_____ Country of Birth:________________________________________
Living Arrangement:_ ________________________________________________________________
___________________________________________________________________________________
Jobs/Schools/Activities:_ ______________________________________________________________
___________________________________________________________________________________
Estimated Infectious Period: _____/_____/_____ — _____/_____/_____
INH Susceptibility:  susceptible
BCG:  yes  no/unknown
Birth Date: _____/_____/_____ Sex:_ _____ County:_____________________________ Previous TST:  yes  no
Date: _____/_____/_____
Address:__________________________________________________________________
Result: ___________mm
Phone Number(s):__________________________________________________________
Prior TB Disease:
Country of Birth:  U.S.  foreign-born
Arrival in U.S.: mo. _____/ yr. _____
 yes (year:_______ )  no
Exposure Setting:  household  work/school  leisure  other
Completed Treatment:
Exposure Risk:  close  other than close
 for TB disease
Relationship to Index Case:__________________________________________________
 for latent TB infection
 medium
Comments:
 no/unknown
Relevant Medical Condition:_
 yes _____________________
 no
BCG:  yes  no/unknown
Birth Date: _____/_____/_____ Sex:_ _____ County:_____________________________ Previous TST:  yes  no
Date: _____/_____/_____
Address:__________________________________________________________________
Result: ___________mm
Phone Number(s):__________________________________________________________
Prior TB Disease:
Country of Birth:  U.S.  foreign-born
Arrival in U.S.: mo. _____/ yr. _____
 yes (year:_______ )  no
Exposure Setting:  household  work/school  leisure  other
Completed Treatment:
Exposure Risk:  close  other than close
 for TB disease
Relationship to Index Case:__________________________________________________
 for latent TB infection
Name:____________________________________________________________________
Date of Last Exposure: _____/_____/_____ 8-Week Follow-up TST Due: _____/_____/_____
Follow-up Priority:  high (age <5 yrs, medical risk, intense exposure)
Comments:
 medium
 Suspect
 pulmonary  extrapulmonary/respiratory  extrapulmonary/not respiratory
Bacteriology:  sputum smear positive  no positive smear or culture from sputum
 sputum smear negative or unknown, sputum culture positive Symptoms: Onset: _____/_____/_____ Cough?  yes  no
Chest X-ray:  negative for active TB  abnormal, cavitary
 abnormal, non-cavitary
Estimated Level of Infectiousness:  high  low Treatment started: _____/_____/_____
Name:____________________________________________________________________
Date of Last Exposure: _____/_____/_____ 8-Week Follow-up TST Due: _____/_____/_____
Status:  Confirmed Case
Site of Disease:
 no/unknown
Relevant Medical Condition:_
 yes _____________________
 no
Completed by: Agency:  resistant  unknown
CURRENT EVALUATION AND TREATMENT FOR LTBI
MEDICAL HISTORY
CONTACT
Follow-up Priority:  high (age <5 yrs, medical risk, intense exposure)
Page ________
TB Symptoms:  yes_________________________________
TST: Initial Date: _____/_____/_____

no
Result: ________mm
 yes  no
Re-test required?
Final Date: _____/_____/_____
Result: ________mm
Chest X-Ray: Date: _____/_____/_____ Result:  abnormal, consistent
with active TB

negative for active TB
TB Disease:  yes  no Started Therapy for LTBI:
 unknown  yes, date: _____/_____/_____  no
LTBI Meds: INH
RIF
Other
Physician/Clinic:
TB Symptoms:  yes_________________________________
TST: Initial Date: _____/_____/_____

no
Result: ________mm
 yes  no
Re-test required?
Final Date: _____/_____/_____
Result: ________mm
Chest X-Ray: Date: _____/_____/_____ Result:  abnormal, consistent
with active TB

negative for active TB
TB Disease:  yes  no Started Therapy for LTBI:
 unknown  yes, date: _____/_____/_____  no
LTBI Meds: INH
RIF
Other
Physician/Clinic:
Phone: Date Submitted:
TUBERCULOSIS CONTACT INVESTIGATION REPORT CONTINUED
INDEX CASE NAME:
BCG:  yes  no/unknown
Birth Date: _____/_____/_____ Sex:_ _____ County:_____________________________ Previous TST:  yes  no
Date: _____/_____/_____
Address:__________________________________________________________________
Result: ___________mm
Phone Number(s):__________________________________________________________
Prior TB Disease:
Country of Birth:  U.S.  foreign-born
Arrival in U.S.: mo. _____/ yr. _____
 yes (year:_______ )  no
Exposure Setting:  household  work/school  leisure  other
Completed Treatment:
Exposure Risk:  close  other than close
 for TB disease
Relationship to Index Case:__________________________________________________
 for latent TB infection
Name:____________________________________________________________________
Date of Last Exposure: _____/_____/_____ 8-Week Follow-up TST Due: _____/_____/_____
Follow-up Priority:  high (age <5 yrs, medical risk, intense exposure)
 medium
Comments:
 no/unknown
Relevant Medical Condition:_
 yes _____________________
 no
BCG:  yes  no/unknown
Birth Date: _____/_____/_____ Sex:_ _____ County:_____________________________ Previous TST:  yes  no
Date: _____/_____/_____
Address:__________________________________________________________________
Result: ___________mm
Phone Number(s):__________________________________________________________
Prior TB Disease:
Country of Birth:  U.S.  foreign-born
Arrival in U.S.: mo. _____/ yr. _____
 yes (year:_______ )  no
Exposure Setting:  household  work/school  leisure  other
Completed Treatment:
Exposure Risk:  close  other than close
 for TB disease
Relationship to Index Case:__________________________________________________
 for latent TB infection
Name:____________________________________________________________________
Date of Last Exposure: _____/_____/_____ 8-Week Follow-up TST Due: _____/_____/_____
Follow-up Priority:  high (age <5 yrs, medical risk, intense exposure)
 medium
Comments:
 no/unknown
Relevant Medical Condition:_
 yes _____________________
 no
BCG:  yes  no/unknown
Birth Date: _____/_____/_____ Sex:_ _____ County:_____________________________ Previous TST:  yes  no
Date: _____/_____/_____
Address:__________________________________________________________________
Result: ___________mm
Phone Number(s):__________________________________________________________
Prior TB Disease:
Country of Birth:  U.S.  foreign-born
Arrival in U.S.: mo. _____/ yr. _____
 yes (year:_______ )  no
Exposure Setting:  household  work/school  leisure  other
Completed Treatment:
Exposure Risk:  close  other than close
 for TB disease
Relationship to Index Case:__________________________________________________
 for latent TB infection
Name:____________________________________________________________________
Date of Last Exposure: _____/_____/_____ 8-Week Follow-up TST Due: _____/_____/_____
Follow-up Priority:  high (age <5 yrs, medical risk, intense exposure)
Comments:
 medium
 no/unknown
Relevant Medical Condition:_
 yes _____________________
 no
Page ________
TB Symptoms:  yes_________________________________
TST: Initial Date: _____/_____/_____

no
Result: ________mm
 yes  no
Re-test required?
Final Date: _____/_____/_____
Result: ________mm
Chest X-Ray: Date: _____/_____/_____ Result:  abnormal, consistent
with active TB
 negative for active TB
TB Disease:  yes  no Started Therapy for LTBI:
 unknown  yes, date: _____/_____/_____  no
LTBI Meds: INH
RIF
Other
Physician/Clinic:
TB Symptoms:  yes_________________________________
TST: Initial Date: _____/_____/_____

no
Result: ________mm
 yes  no
Re-test required?
Final Date: _____/_____/_____
Result: ________mm
Chest X-Ray: Date: _____/_____/_____ Result:  abnormal, consistent
with active TB
 negative for active TB
TB Disease:  yes  no Started Therapy for LTBI:
 unknown  yes, date: _____/_____/_____  no
LTBI Meds: INH
RIF
Other
Physician/Clinic:
TB Symptoms:  yes_________________________________
TST: Initial Date: _____/_____/_____

no
Result: ________mm
 yes  no
Re-test required?
Final Date: _____/_____/_____
Result: ________mm
Chest X-Ray: Date: _____/_____/_____ Result:  abnormal, consistent
with active TB
 negative for active TB
TB Disease:  yes  no Started Therapy for LTBI:
 unknown  yes, date: _____/_____/_____  no
LTBI Meds: INH
RIF
Other
Physician/Clinic:
5/07
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