Health Department Homeless TB Data Collection Instrument

Local Program Interventions Addressing TB among the Homeless

Form approved

OMB No. 0920-0879

Expiration Date 03/31/2014

ATTACHMENT B: Health Department Homeless TB Data Collection Instrument

1. Demographics and control program characteristics

Jurisdiction _______________Fill in___________________________________

Population size of your jurisdiction (check the appropriate box)

Less than 50,000 people
Between 50,000 and 100,000 people
Between 100,000 and 500,000 people
More than 500,000 people

Number of TB cases in 2012 _________Fill in_______________________

1. Please indicate how the TB program is organized within the health department:

(check the appropriate box)

Stand alone
Integrated with other communicable diseases
Integrated with other program (specify)
Other (please specify)

2. How many staff are solely dedicated to your TB Control Program? ______

3. Please indicate how many staff members work in your TB control program, how much of their time is dedicated to working in the TB control program and if communicating with homeless service providers is part of their work responsibilities:

(please indicate how many staff in each category)

Type of staff member	Number	Dedicated time to TB (%)	Designated to communicate with homeless service providers (Y/N)
Medical Doctors
Registered Nurses
Licensed Practical Nurses
Medical Assistants or Technicians
DIS/DOT workers
Clinical/Public Health Investigators
Epidemiologists
Administrative staff members
Other

4. What is your job title?­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­______________Fill in______________________

2. Perception and assessment of the problem

1. Do you perceive TB among homeless persons is a problem in your jurisdiction?

Yes / No

2. How is the housing status of a TB patient assessed (for documentation on the RVCT)?
   (Check all that apply)

Interview
Chart review
Homeless registry (HMIS)
Other (please specify)

3. Does your TB program have written guidance on addressing TB among the homeless? (For example, written policy or plan to address TB among the homeless, as described in CDC guidelines published by the Division of TB Elimination and the Advisory Council for the Elimination of TB in 1992).

Yes / No

Written policy	Yes / No
Do you have a written policy on TB case finding and treatment completion among homeless persons?
Do you have a written policy on Latent TB Infection (LTBI) screening and treatment for homeless persons if HIV infection or other medical condition existed that increases TB?
Do you have a written policy on examining and potentially retreating inadequately treated TB disease and infection among homeless persons?
Do you have a written policy on conducting contact investigations for cases reported as homeless, including shelter screenings?

Please provide any additional details about use of written policies to address TB among homeless persons.

4. If no, do you employ guidance from other jurisdictions?

Yes / No

3. Tuberculosis outbreaks

Please indicate whether you have had any TB outbreaks involving any cases among homeless persons during the time period listed in the first column (mark zero if there have been no outbreaks involving homeless persons)

Time Period	Number of outbreaks among homeless persons	Shelter involved in the outbreak(s)? Yes/No
2011–2013
2008–2010
2008–2005

4. Working with health care for the homeless providers and shelters

1. Please indicate the approximate frequency of meetings with homeless service providers (for example, monthly meetings with shelter directors or health care for the homeless providers): (check the appropriate box)

More than 1 each month
Monthly
Quarterly
2 times each year
Annually
Never

1. If you are conducting meetings, please check those who are invited to attend: (check all that apply)

Health Care for the Homeless clinic staff / representatives
Shelter directors
Shelter staff members
Homeless advocacy agency staff (e.g., Coalition for the Homeless)
Other (please specify

2. Please check if you have MOUs (memorandum of understanding) with homeless service agencies to provide TB care (for example, a health care for the homeless clinic to conduct TB screening): (check all that apply)

No memorandum of understanding
TB screening
Chest radiography
Treatment of latent infection
Treatment of active TB disease

5. Screening

1. Do you perform tuberculosis screening for individuals currently experiencing homelessness?

Yes / No

1. If yes, please indicate screening location(s) (check all that apply)

Location
Public health (TB) clinic
Community Health Centers
Health Care for the Homeless clinics
Homeless shelters
Mobile clinic
Street outreach
Health fairs
Other (please specify)

2. If yes, what TB screening tests are used to screen homeless individuals?

(check all that apply)

Tuberculin skin test
IGRA
Symptom screen
Chest radiograph
Sputum examination (AFB smear)

2. Do you perform HIV screening for individuals currently experiencing homelessness?

Yes / No

6. TB Control Program Interventions

   1. Contact investigations

      1. How often are contact investigations conducted once a contagious TB patient is identified? (check the appropriate box)

None or rarely (0%)
As needed (25%)
Sometimes (50%)
Almost always (75%)
Always (>90%)

2. How often are contact investigations conducted once a contagious TB patient with a history of homelessness or is currently homeless is identified?

(check the appropriate box)

None or rarely (0%)
As needed (25%)
Sometimes (50%)
Almost always (75%)
Always (>90%)

In the last year,
Has a contact investigation been deemed not feasible for a homeless TB patient?	Yes/ No
Have location based investigations followed after identifying a homeless TB person in your jurisdiction?	Yes / No
How many homeless TB patients had at least 1 name based contact?	Number
How many homeless TB persons had 4 or more name based contacts?	Number

2. Housing as a TB control program intervention

1. How often are homeless TB patients provided housing after diagnosis in your jurisdiction? (check the appropriate box)

None or rarely (0%)
As needed (25%)
Sometimes (50%)
Almost always (75%)
Always (>90%)

1. Please list the top 5 types of facilities/organizations that provide housing for homeless TB patients in your jurisdiction (examples: hotel, motel, nonprofit organization like American Lung Association, local hospital)

___________________________________________

2. For what period of time are homeless TB cases housed after diagnosis?

(check all that apply)

While infectious (i.e., smear or culture positive)
During intensive phase (i.e., 2 months)
Based on patient need
Until treatment is completed (i.e., 6–9 months)
Until the patient is otherwise housed
Other (specify)

3. Treatment

   1. Do you ever provide treatment for LATENT TB infection to your homeless patients? Yes / No

2. What regimens are used to treat latent TB infection among the homeless?

(check all that apply)

LTBI treatment regimen
9 months INH
6 months INH
12 weeks INH/Rifapentine
Biweekly INH for 9 months
4 months Rifampin
Other (please specify)

3. If yes, is the treatment directly observed?

(check all that apply)

Directly Observed Treatment for:
All homeless patients
Pediatric patients
Patients on 12 weeks isoniazid (INH)/Rifapentine
Patients on biweekly INH for 9 months
Patients on 4 months Rifampin
Never
Other (please specify)

4. Providing incentives

1. Are any incentives (monetary or in-kind) used with homeless patients during treatment for ACTIVE TB disease?

Yes / No

2. Are any incentives (monetary or in-kind) used with homeless patients during treatment for LATENT TB infection?

Yes / No

Public reporting burden of this collection of information is estimated to average 20 minutes per response, including the time for reviewing the 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 aspects of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Rd, NE, MS D-75, Atlanta, GA 30333; ATTN: PRA (0920-0879).