Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
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