Form CDC 72.9A CDC 72.9A Report of Verified Case of Tuberculosis

REPORT OF VERIFIED CASE
OF TUBERCULOSIS

Patient’s Name _________________________________________________________
(Last)

(First)

(M.I.)

Street Address _____________________________________________________________________________________ _______________
(Number, Street, City, State)

(Zip Code)

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR DISEASE CONTROL
AND PREVENTION (CDC)
ATLANTA, GEORGIA 30333

REPORT OF VERIFIED CASE OF TUBERCULOSIS

FORM APPROVED OMB NO. 0920-0026 Exp. Date 00/00/0000

3. Case Numbers

1. Date Reported
Day

Month

Locally Assigned Identification Number

State Code

City/County
Case Number

2. Date Submitted
Month

Year Reported (YYYY)

State Case
Number

Year

Reason:
Day

Linking State
Case Number

Year

Linking State
Case Number

4. Reporting Address for Case Counting

8. Date of Birth
Year

Day

Month

City
Within City Limits

Yes

No

9. Sex at Birth
County

Male

Female

11. Race (select one or more)
American Indian or
Alaska Native
Asian: Specify____________

10. Ethnicity (select one):
Zip Code

Black or African American
Hispanic or Latino

6. Date Counted

5. Count Status (select one)

Native Hawaiian or
Other Pacific Islander:
Specify_________________

Not Hispanic
or Latino

Year

Day

Month

Count as a TB case

White

Verified Case: Counted by
7. Previous Diagnosis of TB Disease
another U.S. area (e.g., county, state)
Verified Case: TB treatment
initiated in another country
Specify______________________

Yes

12. Country of Birth
Specify_______________________________

No

13. Month-Year Arrived in U.S.
If YES, enter year of previous TB disease diagnosis:

Month

Year

Verified Case: Recurrent TB
within 12 months

14. Pediatric TB Patients (<15 years old)

16. Site of TB Disease (select all that apply)

Patient lived outside U.S. for >2 months?

Pulmonary

Genitourinary

If YES, list countries, specify: _______________________________________

Pleural

Meningeal

Country of Birth for Primary Guardian(s), specify:

Lymphatic: Cervical

Peritoneal

Lymphatic: Intrathoracic

Other: enter anatomic code(s)
(see list):

Lymphatic: Axillary

Site not stated

Yes

No

Unknown

Guardian 1________________________________________________________
Guardian 2________________________________________________________
15. Status at TB Diagnosis
Alive

Dead

Lymphatic: Other
Year

Day

Month

2

3

Lymphatic: Unknown

If DEAD, enter date of death:
If DEAD, was TB a cause of death?

{

1

Laryngeal
Yes

No

Unknown

Bone and/or Joint

Public reporting burden of this collection of information is estimated to average 35 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it
displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC,
Project Clearance Officer, 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0026). Do not send the completed form to this address.
Information contained on this form which would permit identification of any individual has been collected with a guarantee that it will be held in strict confidence, will be used only for surveillance purposes,
and will not be disclosed or released without the consent of the individual in accordance with Section 308(d) of the Public Health Service Act (42 U.S.C. 242m).
CDC 72.9A Rev 10/11/2007

1st Copy

REPORT OF VERIFIED CASE OF TUBERCULOSIS

Page 1 of 3

Patient’s Name _________________________________________________________
(Last)

(First)

State Case No. _______________________

(M.I.)

REPORT OF VERIFIED CASE
OF TUBERCULOSIS

REPORT OF VERIFIED CASE OF TUBERCULOSIS
17. Sputum Smear (select one)
Positive

19. Smear/Pathology/Cytology of Tissue and
Other Body Fluids (select one)

18. Sputum Culture (select one)

Not Done

Positive

Not Done

Negative

Unknown

Negative

Unknown

Date Collected:

Positive

Not Done

Negative

Unknown

Date Collected:
Year

Day

Month

Month

Year

Day

Date Collected:
Day

Month

20. Culture of Tissue and Other Body Fluids
(select one)
Positive

Not Done

Negative

Unknown

Date Result Reported:
Month

Year

Day

Reporting Laboratory Type (select one):
Public Health
Laboratory

Enter anatomic code (see list):

Commercial
Laboratory

Other

21. Nucleic Acid Amplification Test Result (select one)

Date Collected:
Year

Day

Month

Year

Positive

Not Done

Negative

Unknown

Type of exam (select all that apply):
Smear

Indeterminate

Pathology/Cytology

Date Collected:
Month

Year

Day

Enter anatomic code (see list):
Date Result Reported:

Enter specimen type:

Year

Day

Month

Sputum
or
Reporting Laboratory Type (select one):

Public Health
Laboratory

If not Sputum, enter anatomic code (see list):

Commercial
Laboratory

Other

Date Result Reported:
Month

Year

Day

Reporting Laboratory Type (select one):

Public Health
Laboratory

Commercial
Laboratory

Other

Initial Chest Radiograph and Other Chest Imaging Study
22B. Initial Chest CT Scan or Other Chest Imaging Study

22A. Initial Chest Radiograph
Normal

Abnormal

Not Done

Unknown

Normal

For ABNORMAL Initial Chest Radiograph:

Not Done

Unknown

For ABNORMAL Initial Chest CT Scan or Other Chest Imaging Study:

Evidence of a cavity:

Yes

No

Unknown

Evidence of a cavity:

Yes

No

Unknown

Evidence of miliary TB:

Yes

No

Unknown

Evidence of miliary TB:

Yes

No

Unknown

23. Tuberculin (Mantoux) Skin Test at Diagnosis
(select one)

Abnormal

Positive

Not Done

Negative

Unknown

Date Tuberculin Skin Test (TST) Placed:
Month

Day

Year

24. Interferon Gamma Release Assay for
Mycobacterium tuberculosis at Diagnosis
(select one)

Positive

Not Done

Negative

Unknown

Indeterminate

TB Symptoms
Abnormal Chest Radiograph
Contact Investigation
Targeted Testing

Date Collected:
Month

25. Primary Reason Evaluated for TB Disease
(select one)

Day

Health Care Worker

Year

Employment/Administrative Testing
Immigration Medical Exam
Incidental Lab Result

Test type:
Millimeters (mm) of induration:
CDC 72.9A Rev 10/11/2007

Specify__________________________________
1st Copy

Unknown

REPORT OF VERIFIED CASE OF TUBERCULOSIS

Page 2 of 3

Patient’s Name _________________________________________________________
(Last)

(First)

State Case No. _______________________

(M.I.)

REPORT OF VERIFIED CASE
OF TUBERCULOSIS

REPORT OF VERIFIED CASE OF TUBERCULOSIS
26. HIV Status at Time of Diagnosis
Negative

Indeterminate

Not Offered

Unknown

Positive

Refused

Test Done, Results Unknown

If POSITIVE, enter:
City/County HIV/AIDS
Patient Number:

State HIV/AIDS
Patient Number:

28. Resident of Correctional Facility at Time of Diagnosis

27. Homeless Within Past Year
No

Yes

Unknown

No

Yes

Unknown
If YES, under custody of
Immigration and Customs
Enforcement?

If YES, (select one):
Federal Prison

State Prison

29. Resident of Long-Term Care Facility at Time of Diagnosis

Local Jail

Other Correctional Facility

Juvenile Correction Facility

Unknown

No

Yes

No

Yes

Unknown

If YES, (select one):

Nursing Home

Residential Facility

Alcohol or Drug Treatment Facility

Hospital-Based Facility

Mental Health Residential Facility

Other Long-Term Care Facility

Unknown

30. Primary Occupation Within the Past Year (select one)
Health Care Worker

Correctional Facility Employee

Migrant/Seasonal Worker

Retired

Not Eligible for Employment (e.g. student, homemaker, disabled person)

Other Occupation

Unemployed

Unknown

31. Injecting Drug Use Within Past Year
No

Yes

32. Non-Injecting Drug Use Within Past Year

Unknown

No

Yes

33. Excess Alcohol Use Within Past Year

Unknown

No

Yes

Unknown

34. Additional TB Risk Factors (select all that apply)
Contact of MDR-TB Patient

Incomplete LTBI Therapy

Diabetes Mellitus

Other Specify ___________________________

Contact of Infectious TB Patient

TNF-a Antagonist Therapy

End-Stage Renal Disease

None

Missed Contact

Post-organ Transplantation

Immunosuppression (not HIV/AIDS)

35. Immigration Status at First Entry to the U.S.
Not Applicable(U.S.-born)

Tourist Visa

Other Immigration Status

Immigrant Visa

Family/Fiancé Visa

Unknown

Student Visa

Refugee

Employment Visa

Asylee or Parolee

36. Date Therapy Started
Month

Day

37. Initial Drug Regimen
Year

No Yes Unk

No Yes Unk

No Yes Unk

Isoniazid

Ethionamide

Moxifloxacin

Rifampin

Amikacin

Cycloserine

Pyrazinamide

Kanamycin

Para-Amino

Salicylic Acid

Ethambutol

Capreomycin

Other

Streptomycin

Ciprofloxacin

Rifabutin

Levofloxacin

Rifapentine

Ofloxacin

Specify ___________________________

Other

Specify ___________________________

Comments:
____________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________

CDC 72.9A Rev 10/11/2007

1st Copy

REPORT OF VERIFIED CASE OF TUBERCULOSIS

Page 3 of 3

REPORT OF VERIFIED CASE
OF TUBERCULOSIS

Patient’s Name _________________________________________________________
(Last)

(First)

(M.I.)

Street Address _____________________________________________________________________________________ _______________
(Number, Street, City, State)

(Zip Code)

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR DISEASE CONTROL
AND PREVENTION (CDC)
ATLANTA, GEORGIA 30333

REPORT OF VERIFIED CASE OF TUBERCULOSIS

FORM APPROVED OMB NO. 0920-0026 Exp. Date 00/00/0000

Initial Drug Susceptibility Report
Year Counted

(Follow Up Report – 1)

State Case
Number
City/County
Case Number

Submit this report for all culture-positive cases.
38. Genotyping Accession Number
Isolate submitted for genotyping:

No

Yes

If YES, genotyping accession number for episode:
39. Initial Drug Susceptibility Testing
Was drug susceptibility testing done?

No

Yes

Unknown

If NO or UNKNOWN, do not complete the rest of Follow Up Report –1
If YES, enter date FIRST isolate collected for which drug susceptibility
testing was done:
Month

Enter specimen type:

Year

Day

Sputum
or
If not Sputum, enter anatomic code (see list):

40. Initial Drug Susceptibility Results
Resistant

Susceptible

Not Done

Unknown

Resistant

Susceptible

Not Done

Unknown

Isoniazid

Capreomycin

Rifampin

Ciprofloxacin

Pyrazinamide

Levofloxacin

Ethambutol

Ofloxacin

Streptomycin

Moxifloxacin

Rifabutin

Other Quinolones

Rifapentine

Cycloserine

Ethionamide

Para-Amino Salicylic Acid

Amikacin

Other

Kanamycin

Specify ___________________________________________________
Other

Specify ___________________________________________________

Comments:
____________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________

Public reporting burden of this collection of information is estimated to average 35 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it
displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC,
Project Clearance Officer, 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0026). Do not send the completed form to this address.
Information contained on this form which would permit identification of any individual has been collected with a guarantee that it will be held in strict confidence, will be used only for surveillance purposes,
and will not be disclosed or released without the consent of the individual in accordance with Section 308(d) of the Public Health Service Act (42 U.S.C. 242m).
CDC 72.9B Rev 10/11/2007

1st Copy

REPORT OF VERIFIED CASE OF TUBERCULOSIS

Follow Up Report -1

REPORT OF VERIFIED CASE
OF TUBERCULOSIS

Patient’s Name _________________________________________________________
(Last)

(First)

(M.I.)

Street Address _____________________________________________________________________________________ _______________
(Number, Street, City, State)

(Zip Code)

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR DISEASE CONTROL
AND PREVENTION (CDC)
ATLANTA, GEORGIA 30333

REPORT OF VERIFIED CASE OF TUBERCULOSIS

FORM APPROVED OMB NO. 0920-0026 Exp. Date 00/00/0000

Case Completion Report
Year Counted

(Follow Up Report – 2)

State Case
Number
City/County
Case Number

Submit this report for all cases in which the patient was alive at diagnosis.
41. Sputum Culture Conversion Documented

No

Month

Day

Yes

Unknown

If NO, enter reason for not documenting sputum culture conversion (select one):

If YES, enter date specimen collected for first
consistently negative sputum culture:
Year

Clinically Improved: No Follow-up

Sputum Despite Induction

Patient Refused

No Follow-up Sputum Collected

Other Specify _________________________________________

Died

Unknown

Patient Lost to Follow-Up

42. Moved
Did the patient move during TB therapy?

No

Yes

If YES, moved to where (select all that apply):
In state, out of jurisdiction (enter city/county) Specify________________________________________ Specify________________________________________
Out of state (enter state)

Specify________________________________________ Specify________________________________________

Out of the U.S. (enter country)

Specify________________________________________ Specify________________________________________

If moved out of the U.S., transnational referral?
43. Date Therapy Stopped
Month

Day

No

Yes

44. Reason Therapy Stopped or Never Started (select one)
Year

If DIED, indicate cause of death (select one):

Completed Therapy

Not TB

Lost

Died

Related to TB disease

Unrelated to TB disease

Uncooperative or Refused

Other

Related to TB therapy

Unknown

Adverse Treatment Event

Unknown

45. Reason Therapy Extended >12 months (select all that apply)
Rifampin resistance

Non-adherence

Clinically Indicated – other reasons

Adverse Drug Reaction

Failure

Other Specify _________________________________________

46. Type of Outpatient Health Care Provider (select all that apply)
Local/State Health Department (HD)

IHS, Tribal HD, or Tribal Corporation

Inpatient Care Only

Private

Institutional/Correctional

Other

Unknown

Comments:
____________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________
Public reporting burden of this collection of information is estimated to average 35 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it
displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC,
Project Clearance Officer, 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0026). Do not send the completed form to this address.
Information contained on this form which would permit identification of any individual has been collected with a guarantee that it will be held in strict confidence, will be used only for surveillance purposes,
and will not be disclosed or released without the consent of the individual in accordance with Section 308(d) of the Public Health Service Act (42 U.S.C. 242m).
CDC 72.9C Rev 10/11/2007

1st Copy

REPORT OF VERIFIED CASE OF TUBERCULOSIS

Follow Up Report -2

Patient’s Name _________________________________________________________
(Last)

(First)

(M.I.)

State Case No. _______________________

REPORT OF VERIFIED CASE
OF TUBERCULOSIS

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR DISEASE CONTROL
AND PREVENTION (CDC)
ATLANTA, GEORGIA 30333

REPORT OF VERIFIED CASE OF TUBERCULOSIS

FORM APPROVED OMB NO. 0920-0026 Exp. Date 00/00/0000

Case Completion Report - Continued

(Follow Up Report – 2)

47. Directly Observed Therapy (DOT) (select one)
No, Totally Self-Administered
Yes, Totally Directly Observed
Yes, Both Directly Observed and Self-Administered
Unknown
Number of weeks of directly observed therapy (DOT)
48. Final Drug Susceptibility Testing
Was follow-up drug susceptibility testing done?

No

Yes

Unknown

If NO or UNKNOWN, do not complete the rest of Follow Up Report –2
If YES, enter date FINAL isolate collected for which drug susceptibility
testing was done:
Month

Enter specimen type:

or

Year

Day

Sputum

If not Sputum, enter anatomic code (see list):
49. Final Drug Susceptibility Results
Resistant

Susceptible

Not Done

Unknown

Resistant

Susceptible

Not Done

Isoniazid

Capreomycin

Rifampin

Ciprofloxacin

Pyrazinamide

Levofloxacin

Ethambutol

Ofloxacin

Streptomycin

Moxifloxacin

Rifabutin

Other Quinolones

Cycloserine

Para-Amino Salicylic Acid

Other

Rifapentine

Ethionamide

Amikacin

Kanamycin

Unknown

Specify ___________________________________________________
Other

Specify ___________________________________________________

Comments:
____________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________
Public reporting burden of this collection of information is estimated to average 35 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it
displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC,
Project Clearance Officer, 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0026). Do not send the completed form to this address.
Information contained on this form which would permit identification of any individual has been collected with a guarantee that it will be held in strict confidence, will be used only for surveillance purposes,
and will not be disclosed or released without the consent of the individual in accordance with Section 308(d) of the Public Health Service Act (42 U.S.C. 242m).
CDC 72.9C Rev 10/11/2007

1st Copy

REPORT OF VERIFIED CASE OF TUBERCULOSIS

Follow Up Report -2