Report of Verified Case of TB

Patient’s Name _________________________________________________________
(Last) (First) (M.I.)
Street Address _____________________________________________________________________________________
_______________

REPORT OF VERIFIED CASE
OF TUBERCULOSIS

(ZIP CODE)

FORM APPROVED OMB NO. 0920-0026 Exp. Date 05/31/2014

REPORT OF VERIFIED CASE OF TUBERCULOSIS
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 (select one)

Yes

No

9. Sex at Birth (select one) 11. Race (select one or more)
American Indian or
Male
Female
Alaska Native

County

10. Ethnicity (select one)

ZIP CODE

Asian: Specify____________
Black or African American

5. Count Status (select one)

Hispanic or Latino

6. Date Counted

Countable TB Case

Not Hispanic
or Latino

Year

Day

Month

Native Hawaiian or
Other Pacific Islander:
Specify_________________
White

Count as a TB case
7. Previous Diagnosis of TB Disease (select one)

Noncountable TB Case
Verified Case: Counted by
another U.S. area (e.g., county, state)

Yes

Verified Case: TB treatment
initiated in another country
Specify______________________

No

12. Country of Birth
“U.S.-born” (or born abroad to a parent who was a U.S. citizen)
(select one)
Yes
No
Country of birth: Specify_______________________________

If YES, enter year of previous TB disease diagnosis:

13. Month-Year Arrived in U.S.
Month Year

Verified Case: Recurrent TB within 12
months after completion of therapy
14. Pediatric TB Patients (<15 years old)

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

Country of Birth for Primary Guardian(s): Specify
Guardian 1________________________________________________________

Pulmonary

Bone and/or Joint

Guardian 2________________________________________________________

Pleural

Genitourinary

Patient lived outside U.S. for >2 months?
(select one)

Lymphatic: Cervical

Meningeal

Lymphatic: Intrathoracic

Peritoneal

Lymphatic: Axillary

Other: Enter anatomic code(s)
(see list):
Site not stated

Yes

No

Unknown

If YES, list countries, specify: _______________________________________
15. Status at TB Diagnosis (select one)
Alive

Dead

Lymphatic: Other

Year

Day

Month

Lymphatic: Unknown

If DEAD, enter date of death:

Laryngeal

{

1
2

3

If DEAD, was TB a cause of death? (select one)
Yes

No

Unknown

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 09/15/2008 CS224078-A

1st Copy

REPORT OF VERIFIED CASE OF TUBERCULOSIS

Page 1 of 3

REPORT OF VERIFIED CASE
OF TUBERCULOSIS

Patient’s Name _________________________________________________________ State Case No. _______________________
(Last) (First) (M.I.)

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

Positive

Not Done

Negative

Unknown

Date Collected:
Month

18. Sputum Culture (select one)

Positive

Not Done

Negative

Unknown

Day

Year

Day

Year

Date Collected:
Month

Date Result Reported:

Reporting Laboratory Type (select one):

Public Health
Laboratory

Year

Day

Month

Commercial
Laboratory

Other

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

Positive
Negative

Enter anatomic code
(see list):

Date Collected:

Not Done
Unknown

Year

Day

Month

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

Positive
Negative

Enter
anatomic code
(see list):

Date Collected:

Not Done
Unknown

Year

Day

Month

Reporting Laboratory Type (select one):

Public Health
Laboratory

Type of exam (select all that apply):
Smear

Pathology/Cytology

Date Result Reported:
Year

Day

Month

Commercial
Laboratory

Other

21. Nucleic Acid Amplification Test Result (select one)
Positive
Negative

Not Done
Unknown

Date Result Reported:

Date Collected:
Month

Year

Day

Year

Day

Month

Indeterminate
Reporting Laboratory Type (select one):

Enter specimen type:
Sputum
OR
If not Sputum, enter anatomic code (see list):

Public Health
Laboratory

Commercial
Laboratory

Other

Initial Chest Radiograph and Other Chest Imaging Study
22A. Initial Chest Radiograph
(select one)

Normal

Abnormal* (consistent with TB)

Not Done

Unknown

* For ABNORMAL Initial Chest Radiograph: Evidence of a cavity (select one):
Evidence of miliary TB (select one):

22B. Initial Chest CT Scan or
Other Chest Imaging
Study (select one)

Normal

Abnormal* (consistent with TB)

Not Done

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

Not Done

Negative

Unknown

No

Unknown

Yes

No

Unknown

Unknown

Evidence of a cavity (select one):

Yes

No

Unknown

Evidence of miliary TB (select one):

Yes

No

Unknown

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

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

Yes

Date Tuberculin Skin Test (TST) Placed:
Month

Day

Year

Millimeters (mm)
of induration:

TB Symptoms
Abnormal Chest Radiograph (consistent with TB)
Contact Investigation

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

Positive

Not Done

Negative

Unknown

Indeterminate
CDC 72.9A Rev 09/15/2008 CS224078-A

Targeted Testing

Date Collected:
Month

Year

Day

Health Care Worker
Employment/Administrative Testing
Immigration Medical Exam

Test type:

Incidental Lab Result

Specify__________________________________
1st Copy

Unknown
REPORT OF VERIFIED CASE OF TUBERCULOSIS

Page 2 of 3

Patient’s Name _________________________________________________________ State Case No. _______________________

REPORT OF VERIFIED CASE
OF TUBERCULOSIS

(Last) (First) (M.I.)

REPORT OF VERIFIED CASE OF TUBERCULOSIS
26. HIV Status at Time of Diagnosis (select one)
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 (select one)

27. Homeless Within Past Year
(select one)
No

Yes

Unknown

Federal Prison
Local Jail

State Prison
Juvenile Correction Facility

29. Resident of Long-Term Care Facility at Time of Diagnosis (select one)

No

If YES, (select one):

No

Yes

If YES, (select one):
Other Correctional Facility

No

Unknown

Yes

Unknown
If YES, under custody of
Immigration and Customs
Enforcement? (select one)
Yes

Unknown

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
Migrant/Seasonal Worker
Retired

Correctional Facility Employee
Other Occupation
Unemployed
31. Injecting Drug Use Within Past Year
(select one)
No
Yes
Unknown

Not Seeking Employment (e.g. student, homemaker, disabled person)
Unknown

32. Non-Injecting Drug Use Within Past Year
(select one)
No
Yes
Unknown

33. Excess Alcohol Use Within Past Year
(select one)
No
Yes
Unknown

34. Additional TB Risk Factors (select all that apply)
Contact of MDR-TB Patient (2 years or less)

Incomplete LTBI Therapy

Diabetes Mellitus

Other Specify ______________________

Contact of Infectious TB Patient (2 years or less)

TNF-a Antagonist Therapy

End-Stage Renal Disease

None

Missed Contact (2 years or less)

Post-organ Transplantation

Immunosuppression (not HIV/AIDS)

35. Immigration Status at First Entry to the U.S. (select one)
Not Applicable

Immigrant Visa

Tourist Visa

Asylee or Parolee

• “U.S.-born” (or born abroad to a parent who was a U.S. citizen)

Student Visa

Family/Fiancé Visa

Other Immigration Status

• Born in 1 of the U.S. Territories, U.S. Island Areas, or U.S. Outlying Areas

Employment Visa

Refugee

Unknown

36. Date Therapy Started
Month

Day

37. Initial Drug Regimen (select one option for each drug)
No Yes Unk

Year

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 09/15/2008 CS224078-A

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)

FORM APPROVED OMB NO. 0920-0026 Exp. Date 05/31/2014

REPORT OF VERIFIED CASE OF TUBERCULOSIS
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 (select one):

No

Yes

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

No

Yes

Unknown

If NO or UNKNOWN, do not complete the rest of Follow Up Report –1
If YES, enter date FIRST specimen collected on which initial 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 (select one option for each drug)
Resistant

Susceptible

Not Done

Unknown

Resistant

Susceptible

Not Done

Isoniazid

Capreomycin

Rifampin

Ciprofloxacin

Pyrazinamide

Levofloxacin

Ethambutol

Ofloxacin

Streptomycin

Moxifloxacin

Rifabutin

Other Quinolones

Rifapentine

Cycloserine

Ethionamide

Para-Amino Salicylic Acid

Amikacin

Other

Specify ___________________________________________________

Kanamycin

Other

Unknown

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 09/15/2008 CS224078-A

1st Copy

REPORT OF VERIFIED CASE OF TUBERCULOSIS

Follow Up Report -1 / Page 1 of 1

REPORT OF VERIFIED CASE
OF TUBERCULOSIS

Patient’s Name _________________________________________________________
(Last) (First) (M.I.)

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

(ZIP CODE)

FORM APPROVED OMB NO. 0920-0026 Exp. Date 05/31/2014

REPORT OF VERIFIED CASE OF TUBERCULOSIS
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 (select one)

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:
Month

No

Year

No Follow-up
Induction
Sputum Despite

Patient Refused

No Follow-up Sputum and No Induction

Other Specify ____________________________________

Died

Unknown

Patient Lost to Follow-Up

42. Moved
Did the patient move during TB therapy? (select one)

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? (select one)
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 Outpatient

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 09/15/2008 CS224078-A

1st Copy

REPORT OF VERIFIED CASE OF TUBERCULOSIS

Follow Up Report -2 / Page 1 of 2

Patient’s Name _________________________________________________________

State Case No. _______________________

(Last) (First) (M.I.)

REPORT OF VERIFIED CASE
OF TUBERCULOSIS

FORM APPROVED OMB NO. 0920-0026 Exp. Date 05/31/2014

REPORT OF VERIFIED CASE OF TUBERCULOSIS
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? (select one)

No

Yes

Unknown

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

Enter specimen type:

Year

Day

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

49. Final Drug Susceptibility Results (select one option for each drug)
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 09/15/2008 CS224078-A

1st Copy

REPORT OF VERIFIED CASE OF TUBERCULOSIS

Follow Up Report -2 / Page 2 of 2