DS-3030 Tuberculosis Worksheet

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OMB No. 1405-0113

EXPIRATION DATE: xx/xx/xxxx

_{ESTIMATED BURDEN: 20 MINUTES}

_{(See Page 2 – Back of Form)}

U.S. Department of State

TUBERCULOSIS WORKSHEET

For use with DS-2054

Name (Last, First, MI)

Age

Birth Date (mm-dd-yyyy)

Passport Number

Alien (Case) Number

1. Test for Cell-Mediated Immunity to Tuberculosis

Required for applicants 2 through 14 years of age where WHO-estimated TB rate ≥20 per 100,000 and contacts; perform one type only.

TST Date applied (mm-dd-yyyy)

QFT Nil Value: IU

TB Response: TB minus nil IU/ml

T-Spot Nil Value: Number of cells

TB Response: Higher of

Panel A or Panel B minus nil value

Result (mm)

IGRA Date drawn (mm-dd-yyyy)

Positive

Negative

Indeterminant, Borderline, or Equivocal

2. Chest X-Ray Indication (Mark all that apply)

Date Chest X-Ray Taken ^(mm-dd-yyyy)

^{Chest X-Ray not indicated}

^{Age >15 years}

Signs or symptoms of tuberculosis

Known HIV infection

TST ≥10 mm or IGRA positive

Contact: TST > 5 mm or IGRA positive

^{3. Chest X-Ray Findings}

Normal Findings

Abnormal Findings (Indicate category and finding, checking all that apply in the tables below)

Can Suggest Tuberculosis (Need Smears and Cultures)

No Sputum Specimens Required

Infiltrate or consolidation

Cavitary lesion

_{Nodule or mass with poorly defined margins} (such as tuberculoma)

Pleural effusion (perform lateral or decubitus radiograph or ultrasound, if needed)

Hilar/mediastinal adenopathy

Miliary findings

Discrete linear opacity

Discrete nodule(s) without calcification

Volume loss or retraction

Other

Mark as Class B Other on DS 2054

Cardiac

Musculoskeletal

Other, specify in Remarks

Do not mark as Class B Other on DS 2054

Pleural thickening

Diaphragmatic tenting

Calcified pulmonary nodule(s)

Calcified lymph node(s)

Remarks

Radiologist’s Name (Printed) Radiologist's Signature (Required) Date Interpreted (mm-dd-yyyy)

4. Sputum Smears and Cultures Decision

_{No, not indicated - Applicant has no signs or symptoms of TB, no known HIV infection, and:}

X-ray Normal or ‘No specimens required' and test for cell-mediated immunity to TB negative (if performed)

X-ray Normal or ‘No specimens required’ and test for cell-mediated immunity to TB positive (if performed)

Yes, are indicated - Applicant has (Mark all that apply):

Signs or symptoms of TB

^{Chest X-ray suggests TB}

Known HIV infection

End of treatment cultures

5. Sputum Smears and Cultures Results

Sputum Smear Results	Date specimen obtained (mm-dd-yyyy)	Date specimen reported (mm-dd-yyyy)	Positive	Negative
	1.
	2.
	3.

Sputum Culture Results	Date specimen obtained (mm-dd-yyyy)	Date specimen reported (mm-dd-yyyy) *Date of exam on DS 2054	Positive	Negative	NTM	Contaminated
	1.
	2.
	3.

6. Tuberculosis Classification

Applicants may have more than one TB Classification. However, they cannot be classified as both Class B1 TB and Class B2 TB. In addition, applicants cannot be classified as Class B3 TB, Contact Evaluation if they are Class A or Class B1 TB, Extrapulmonary.

No TB Classification

CXR not suggestive of tuberculosis, no signs or symptoms, no known HIV infection, TST or IGRA negative (if performed), not a contact

Class A

Applicant has tuberculosis disease

Class B1 TB, Pulmonary

CXR suggests tuberculosis, or signs and symptoms, or known HIV infection and sputum smears and cultures are negative and not a clinically diagnosed case.

Class B1 TB, Extrapulmonary

Applicants with evidence of extrapulmonary tuberculosis. The anatomic site of infection should be documented.

Anatomic Site of Disease

No treatment

Current treatment

Completed treatment

Class B2 TB, LTBI Evaluation

Applicants who have a tuberculin skin test ≥10 mm or positive IGRA but otherwise have a negative evaluation for tuberculosis. Contacts with TST ≥5 mm or positive IGRA should receive this classification (if they are not already Class B1 TB, Pulmonary).

No LTBI treatment

Current LTBI treatment (Indicate medications in Part 7)

Completed LTBI treatment (Indicate medications in Part 7)

Class B3 TB, Contact Evaluation

Applicants who are a recent contact of a known tuberculosis case.

No preventive treatment

Current preventive treatment (Indicate medications in Part 7)

Completed preventive treatment (Indicate medications in Part 7)

Source Case:

Name

Alien Number

Relationship to Contact

Date Contact Ended (mm-dd-yyyy)

Type of Source Case TB ^{(Mark only one and attach DST results)}

Pansusceptible TB

MDR TB (resistant to at least INH and rifampin)

Drug-resistant TB other than MDR TB Culture negative

Culture results not available

Remarks

7. Previous Tuberculosis Diagnosis and Treatment History for Applicants Diagnosed or Treated Through Panel Physician

Complete this section only if one of the following is true (mark appropriate option):

Applicant was diagnosed with tuberculosis disease by the panel physician

Applicant was on tuberculosis treatment at the time of presentation for their medical examination

How was the diagnosis made: Positive laboratory tests Clinical diagnosis

Diagnostic Chest Radiograph
Facility performing chest radiograph: Date Radiograph obtained (mm-dd-yyyy):
Findings Present
Infiltrate or consolidation Cavitary lesion Nodule or mass with poorly defined margins (such as tuberculoma) Hilar/mediastinal adenopathy Pleural effusion	Miliary findings Discrete linear opacity Discrete nodule(s) without calcification Volume loss or retraction Other Normal or no findings suggestive of tuberculosis

Sputum Smear Results

Date specimen obtained (mm-dd-yyyy)	Date specimen reported (mm-dd-yyyy)	Positive	Negative
1.
2.
3.

Sputum Culture Results

Date specimen obtained (mm-dd-yyyy)	Date specimen reported (mm-dd-yyyy)	Positive	Negative	NTM	Contaminated
1.
2.
3.

Drug Susceptibility Test Results. Attach with DS Forms.

Method of DST:			Date specimen obtained (mm-dd-yyyy)	Date DST reported (mm-dd-yyyy)
MGIT	Agar	LJ

	Drug	Susceptible	Resistant
Required for first-line DST	Isoniazid
	Rifampin
	Ethambutol
	Pyrazinamide
Required for multidrug-resistant cases	Ethionamide
	Amikacin
	Capreomycin
	Para-aminosalycilic acid (PAS)
	Fluoroquinolone, specify:
	Other, specify:

7. Previous Tuberculosis Diagnosis and Treatment History for Applicants Diagnosed or Treated Through Panel Physician, Continued

Were molecular tests used in addition to the required sputum smears, cultures, and DST:

No

Yes (mark all that apply):

Molecular Test	Mycobacterium tuberculosis		Rifampin Resistance		Isoniazid Resistance		Second-Line Test
	Positive	Negative	Positive	Negative	Positive	Negative
Hain Line Probe Assay							Performed, attach results
GeneXpert

Tuberculosis Treatment

Treating physician or institution DGMQ-Designated DOT site: Non-DGMQ-Designated DOT site:
Drug	Dosage	Start Date (mm-dd-yyyy)	End Date (mm-dd-yyyy)
Isoniazid
Rifampin
Ethambutol
Pyrazinamide
Other, specify:

_{PAPERWORK REDUCTION ACT AND CONFIDENTIALITY STATEMENTS}

PAPERWORK REDUCTION ACT STATEMENT

Public reporting burden for this collection of information is estimated to average 20 minutes per response, including time required for searching existing data sources, gathering the necessary documentation, providing the information and/or documents required, and reviewing the final collection. You do not have to supply this information unless this collection displays a currently valid OMB control number. If you have comments on the accuracy of this burden estimate and/or recommendations for reducing it, please send them to [email protected]

_{CONFIDENTIALITY STATEMENT}

AUTHORITIES: The information asked for on this form is requested pursuant to Section 212(a) and 221(d) and as required by Section 222 of the Immigration and Nationality Act. Section 222(f) provides that the records of the Department of State and of diplomatic and consular offices of the United States pertaining to the issuance and refusal of visas or permits to enter the United States shall be considered confidential and shall be used only for the formulation, amendment, administration, or enforcement of the immigration, nationality, and other laws of the United States. Certified copies of such records may, in the discretion of the Secretary of State, be made available to a court provided the court certifies that the information contained in such records is needed in a case pending before the court.

PURPOSE: The U.S. Department of State uses the facts you provide on this form primarily to determine your classification and eligibility for a U.S. immigrant visa. Individuals who fail to submit this form or who do not provide all the requested information may be denied a U.S. immigrant visa. Although furnishing this information is voluntary, failure to provide this information may delay or prevent the processing of your case.

ROUTINE USES: If you are issued an immigrant visa and are subsequently admitted to the United States as an immigrant, the Department of Homeland Security will use the information on this form to issue you a Permanent Resident Card, and, if you so indicate, the Social Security Administration will use the information to issue a social security number. The information provided may also be released to federal agencies for law enforcement, counterterrorism and homeland security purposes; to Congress and courts within their sphere of jurisdiction; and to other federal agencies who may need the information to administer or enforce U.S. laws. More information on the Routine Uses for this collection can be found in the System of Records Notice State-24, Medical Records.

DRAFT6

DS-3030 Page 1 of 1

08-2011