Form PC-262-12 Reactive Tuberculin Test Evaluation Form

OMB Control No. 0420-xxxx Expiration Date xx/xx/xxxx Peace Corps

REACTIVE TUBERCULIN TEST EVALUATION FORM

Dear Medical Provider,

Your patient has applied to serve with the Peace Corps and has reported a history of reactivity to tuberculosis (TB) skin testing or a history of BCG vaccination. In order to accurately evaluate this applicant’s medical status, the Peace Corps needs further information about the applicant’s risk of developing tuberculosis. Please answer the following questions regarding the applicant’s TB status.

1. CURRENT TB TEST (Test must be within the past six months; Mantoux test or QuantiFeron-TB Gold) (No test is required if there is documentation of the size of induration and there is documentation of treatment

Select one

Mantoux Date: mm of induration:

Interferon Gamma Releasing Assay (QuantiFERON^®-TB Gold)

Date: ______________ Result: Positive Negative

T.SPOT TB

Date: ______________ Result: Positive Negative

2. TB TEST HISTORY:

No prior TB test

Prior TB test(s)

Date: mm of induration:

Date: mm of induration:

Date: mm of induration:

BCG vaccine (If reported by applicant, please provide)

Date of vaccination:

III. CURRENT TESTS REQUIRED

Copy of current CXR report with interpretation is required for:

• Applicants with a reported induration or interval change in induration ≥ 10mm

• Applicants with risk factors present (see Section V)

• Applicants with a history of a prior reactive tuberculin test

• Applicants with a history of BCG vaccination and a current reactive tuberculin test

Copy of baseline Liver Functions Tests is required for:

• Applicants currently being treated for latent tuberculosis infection (LTBI)

IV. tREATMENT hISTORY:

Note: In general, treatment of latent tuberculosis infection (LTBI) is required for all Peace Corps applicants who are candidates for this therapy. Before an applicant can be medically cleared, and prior to departure overseas, treatment should be initiated in accordance with Centers for Disease Control (CDC) guidelines.¹ There must be a strong medical reason for not treating preventively, e.g., high risk for hepatitis, etc.

No treatment received

INH therapy received:

Date treatment initiated: Ongoing:

Date treatment completed: ____________________

Full-course of other treatment:

Drug regimen:

Date treatment initiated: ______ Ongoing:

Date treatment completed: ____________________

Full-course or treatment not received

Please explain:

V. RISK ASSESSMENT FOR DEVELOPING ACTIVE TB (Please check yes or no):

YES NO

Person infected with the human immunodeficiency virus.

Close contact (i.e., those sharing the same household or other enclosed environments) of person(s) known or suspected to have tuberculosis.

Foreign-born person who has recently arrived (within five years) from a country that has a high incidence or prevalence of tuberculosis (includes most countries in Asia, Africa, and Latin America).

Resident or employee of high-risk congregate setting (e.g., correctional institution, nursing home, mental institution, or shelter for the homeless).

Person who injects illicit drugs or uses other high-risk substances (e.g., crack cocaine).

Health care worker who is exposed to high-risk clients or is/has been mycobacteriology laboratory personnel.

VI. CURRENT TB SYMPTOMS

YES NO

Cough lasting longer than three weeks

Night sweats (drenching bed clothes that last more than one week)

Unexplained weight loss of 10 pounds or more than 10 percent of normal weight

Fatigue/malaise lasting longer than two weeks

Loss of appetite > two weeks

Fever > 100 degrees lasting > one week

VII. RECOMMENDATIONS FOR FURTHER EVALUATION AND TREATMENT

Name of Physician Signature Date

1 Core Curriculum on Tuberculosis: What the Clinician Should Know, 4^th Edition, 2000. U.S. Department of Health and Human Services and Centers for Disease Control and Prevention.

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