Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017
Case Abstraction Form
Demographics
Question |
Code |
Variable |
RVCT number
|
|
RVCT |
Last Name
|
|
Lname |
First Name
|
|
Fname |
Alternate Names/Nicknames/Aliases:
|
|
Alias |
Date of Birth (MM/DD/YY)
|
|
DOB |
Age (years)
|
|
Age |
Gender (1=Male, 2=Female, 3=Other, 99=missing)
|
|
Sex |
Race/Ethnicity (1=Black, 2=White, 3=Hispanic/Latino, 4= American Indian/Alaskan Native, 5=Native Hawaiian/Pacific Islander, 6=Asian, 7=Other, 99=Missing) [Mark all that apply] |
|
Race |
Tribe If American Indian, then specify tribe: |
|
Tribe |
Tribe A residence If lives on Tribe A reservation, specify which area: 1=northwest of Yuma, 2=southwest of Yuma, 3=south of Yuma |
|
Residence |
If lives elsewhere, specify
|
|
Other |
Locating Information, if available: Addresses: Phones:
How long at this address?
Be sure to list any other known addresses during last 3 years.
|
||
Country of Birth (1=United States, 2=Other [foreign-born], 99=missing)
If foreign-born, then specify country: |
|
Birth
Country |
Date
of arrival (MM/DD/YY)
For patients born outside the United States, |
|
Arrival |
TB Risk Factors
Question |
Code |
Variable |
HIV infection (0=No, 1=Yes, 99=Unknown)
|
|
HIV |
Diabetes (0=No, 1=Yes, 99=Unknown)
|
|
DM |
If diabetic, most recent HbA1C
|
|
A1C |
Chronic Renal Failure (0=No, 1=Yes, 99=Unknown)
|
|
ESRD |
Immunosuppression other than HIV (e.g. organ transplant, chemotherapy, medications such as steroids, TNF blockers. 0=No, 1=Yes, 99=Unknown) |
|
Immune |
Mental illness (0=No, 1=Yes, 99=Unknown) (Axis I diagnosis not related to substance abuse, e.g. mood disorders, schizophrenia, anxiety disorders) |
|
Mental |
Injection drug use-recent (Within 1 year of TB diagnosis. 0=No, 1=Yes, 99=Unknown) |
|
IDU_rvct |
Injection drug use-ever (Prior to 1 year of TB diagnosis. 0=No, 1=Yes, 99=Unknown) |
|
IDU_ever |
Injection drug names (open ended) list all drugs injected ever |
|
IDU_list |
Non-injection
drug use-recent
|
|
NIDU_rvct |
Non-injection
drug use-ever
|
|
NIDU_ever |
Non-Injection drug names (open ended) list all non-injection drugs used ever |
|
NIDU_list |
Excess alcohol use-recent (Within 1 year of TB diagnosis. 0=No, 1=Yes, 99=Unknown) |
|
EtOH_rvct |
Excess alcohol use-ever (Prior to 1 year of TB diagnosis. 0=No, 1=Yes, 99=Unknown) |
|
EtOH_ever |
Smoking commercial tobacco regularly (i.e., most days) for at least 1 year at time of diagnosis (0=No, 1=Yes, 99=Unknown) |
|
Tobacco |
Homeless/unstable housing within 1 year of diagnosis? (0=No, 1=Yes 99=Unknown) |
|
Home1
|
Homeless/unstable housing >1 year before diagnosis? (0=No, 1=Yes 99=Unknown) |
|
Home2
|
Use of homeless shelter within 1 year of diagnosis? 0=No, 1=Yes 99=Unknown |
|
Shelter1 |
Use of homeless shelter >1 year before diagnosis? 0=No, 1=Yes 99=Unknown |
|
Shelter2 |
Shelter names (open ended) list all homeless shelters used |
|
Shelter_list |
At least 1 night in correctional/detention facility within 1 year of diagnosis? (0=No, 1=Yes 99=Unknown) |
|
Incarc1
|
At least 1 night in correctional/detention facility >1 year before diagnosis? (0=No, 1=Yes 99=Unknown) |
|
Incarc2 |
Incarceration facility names (open ended) list all correctional/detention facilities where stayed at least 1 night |
|
Incarc_list |
Residence in long term care facility within 1 year of diagnosis? (0=No, 1=Yes 99=Unknown) |
|
LTCF1 |
Residence in long term care facility>1 year before diagnosis? (0=No, 1=Yes 99=Unknown) |
|
LTCF2
|
If known exposure to TB case, exposure type: (1=own household, 2=homeless shelter, 3=jail, 4=other household, 5=bar, 6= hotel, 7=Other: ______________)
List name of site if known:________________________ |
|
TBexp
ExpOth
ExpSite |
TB Case Characteristics
Question |
Code |
Variable |
How was case recognized or detected? (1=symptoms, 2=contact investigation, 3=routine TB screening by healthcare provider, 4=incidental finding by healthcare provider, 5=other, 99=unknown) |
|
Caserec |
Cough (0=not present 1= present, 99=unknown)
|
|
Cough |
Fever (0=not present 1= present, 99=unknown)
|
|
Fever |
Night Sweats (0=not present 1= present, 99=unknown)
|
|
Sweats |
Weight Loss (0=not present 1= present, 99=unknown)
|
|
Weight |
Other TB Symptoms (list)
|
|
OthSx |
Date of first symptom onset (Enter the first date the patient began experiencing symptoms in the format MM/DD/YY) |
|
DateSx |
Site of disease (1=pulmonary, 2=extrapulmonary, 3=both pulmonary and extrapulmonary) |
|
TBSite |
Diagnostic CXR result (1=Negative, 2=Abnormal, possibly TB, 3=Abnormal, not consistent with TB, 4=Unknown [not completed or not available]) |
|
CXRrslt |
Diagnostic chest radiograph (CXR) result date (Enter the date of the patient’s most recent CXR completed as part of current diagnostic workup leading to patient’s current diagnosis of TB. MM/DD/YY) |
|
CXRdate |
Cavitary disease on CXR? (0=No, 1=Yes, 99=Unknown)
|
|
CavCXR |
Cavitary disease on CT? (0=No, 1=Yes, 99=Unknown) |
|
CavCT |
Sputum AFB smear positive disease? (0=No, 1=Yes, 2=Sputum never submitted)
|
|
Sputum |
Sputum smear converted to negative (0=No, 1=Yes <2 months of treatment, 2=Yes >2 months of treatment, 3=Unknown/NA) |
|
Smearconv
|
Other site AFB smear positive? (0=No, 1=Yes, 99=Unknown) Specify Site:__________________ |
|
OthSmear OthSite |
Culture-confirmed disease? (0=No, 1=sputum only, 2=non-sputum specimen, 3=both sputum and non-sputum specimens, 4=specimens never submitted, 99=Unknown) |
|
Culture |
If culture confirmed, list GENType
|
|
GENType |
Culture converted to negative (0=No, 1=Yes <2 months of treatment, 2=Yes >2 months of treatment, 3=Unknown/NA) |
|
Cxconv
|
Diagnosis date (MM/DD/YY) (the earliest date of the following: positive smear, positive culture, positive PCR test, or abnormal chest x-ray/CT scan) |
|
Dxdate |
Drug susceptibility based on molecular testing (1=Pan-susceptible, 2=INH resistance, 3=rifampin resistance, 4=multiple resistance, including MDR TB, 88=pending, 99=unknown) |
|
Suscept_Mol |
Drug
susceptibility based on culture
|
|
Suscept_DST |
INH resistance level (highest concentration at which isolate is resistant)
|
|
INHR |
RIF resistance level (highest concentration at which isolate is resistant)
|
|
RIFR |
Specify any other detected resistance
|
|
Oth_R |
Diagnostic TST result (Enter the patient’s TST result, if completed as part of the diagnostic workup leading to the patient’s current diagnosis of TB. 1=negative, 2=positive, 3=positive with conversion [>10mm increase in last 2 years], 4=not done due to prior positive TST, 5=not done for other reason, 99=result unknown) |
|
TST |
Diagnostic TST reading (mm reading)
|
|
TSTmm |
Diagnostic TST date (MM/DD/YY)
|
|
TSTdate |
Diagnostic QFT result (Enter the patient’s qualitative QFT result, if completed as part of the diagnostic workup leading to the patient’s current diagnosis of TB. 1=negative, 2=positive, 3=indeterminate, 4=not done, 99=unknown) |
|
QFT |
Diagnostic QFT value (result-nil). (Enter the quantitative result of the patient’s current QFT result, 99=Unknown. Leave blank if not performed.) |
|
QFTvalue |
Diagnostic QFT date (MM/DD/YY)
|
|
QFTdate |
Diagnostic T.Spot result (Enter the patient’s qualitative result, if completed as part of the diagnostic workup leading to the patient’s current diagnosis of TB. 1=negative, 2=positive, 3=indeterminate, 4=borderline, 5=not done, 99=unknown) |
|
TSpot |
Diagnostic T.Spot value (Enter the quantitative result of the patient’s current result, 99=Unknown. Leave blank if not performed.) |
|
TSpotvalue |
Diagnostic T.Spot date (MM/DD/YY)
|
|
TSpotdate |
Treatment (1=On treatment, 2=Completed full treatment, 3=Completed partial treatment, 4=Died during treatment, 5= Died before treatment, 6=died after treatment, 7=awaiting treatment initiation, 8=refused treatment, 99=Unknown) |
|
TBrx
|
Start date of initial TB treatment (Enter the date of antituberculosis medication in the format MM/DD/YY.) |
|
TBRxdate |
If applicable, date of change to MDR TB regimen (Enter the date of antituberculosis medication in the format MM/DD/YY.) |
|
MDRRxdate |
List MDR TB regimen
|
|
MDRregimen |
Date of treatment completion if done (Enter the date of antituberculosis medication in the format MM/DD/YY.) |
|
Rxcomp
|
History of loss to follow-up or non-compliance during this TB treatment course (0= No, 1= Yes, 99=Unknown) |
|
TBfu |
If died, then enter date of death (MM/DD/YY)
|
|
Deathdate |
If died, then enter cause of death
|
|
Deathcause |
Previous TB episodes and LTBI history
Question |
Code |
Variable |
Prior TB disease? (0=No, 1=Yes, 99=Unknown)
|
|
PrevTB |
Year of previous diagnosis (YYYY)
|
|
Prevyr |
If prior TB, exposure type (1=own household, 2=homeless shelter, 3=jail, 4=other household, 5=bar, 6= hotel, 7=Other: ______________) |
|
PrevTBexp
PrevTBexpoth |
If prior TB, drug susceptibility (1=Pan-susceptible, 2=INH resistance, 3=rifampin resistance, 4=multiple resistance, incl. MDR TB, 88=pending, 99=unknown) |
|
Prevresist
|
If prior TB, Genotype (GENType)
|
|
PrevGENtype |
TB treatment completed (0= No, 1= Yes, 2=In progress, 99=Unknown)
|
|
PrevTBRx |
History of loss to follow-up or non-compliance during TB treatment (0= No, 1= Yes, 99=Unknown) |
|
PrevTBfu |
Previous
positive test for LTBI |
|
HxLTBI |
Previous TST result date (Enter the date of the patient’s most recent TST before any test conducted as part of current diagnostic workup leading to patient’s current diagnosis of TB. MM/DD/YY) |
|
PrevTSTdate |
Previous TST result (MM) (Enter the mm reading of the patient’s previous TST result. 99=Unknown) |
|
PrevTSTmm |
Previous TST interpretation (1=Negative, 2=Positive, 3=Unknown)
|
|
PrevTSTrslt |
Previous QFT result date (Enter the date of the patient’s most recent QFT before any a test conducted as part of current diagnostic workup leading to patient’s current diagnosis of TB. MM/DD/YY) |
|
PrevQFTdate |
Previous QFT result (Enter value [result-nil]. 99= unknown)
|
|
PrevQFTnum |
Previous QFT interpretation (1=Negative, 2=Convertor, 3=Unknown) |
|
PrevQFTrslt |
Diagnostic T.Spot result (Enter the patient’s qualitative result, if completed as part of the diagnostic workup leading to the patient’s current diagnosis of TB. 1=negative, 2=positive, 3=indeterminate, 4=not done, 99=unknown) |
|
PrevTSpot |
Diagnostic T.Spot value (Enter the quantitative result of the patient’s current result, 99=Unknown. Leave blank if not performed.) |
|
PrevTSpotvalue |
Diagnostic T.Spot date (MM/DD/YY)
|
|
PrevTSpotdate |
Previous chest radiograph (CXR) result date (Enter the date of the patient’s most recent CXR before any CXR conducted as part of current diagnostic workup leading to patient’s current diagnosis of TB. MM/DD/YY) |
|
DateprevCXR |
Previous CXR result (1=Negative, 2=Abnormal, possibly TB, 3=Abnormal, not consistent with TB, 99=Unknown [not completed or not available]) |
|
PrevCXRrslt |
Initiated treatment for LTBI? 0=offered but refused, 1=never offered by provider, 2=yes, initiated, 99=unknown |
|
LTBIRxStart |
Prior LTBI treatment completed 0= No, 1= Yes, 99=Unknown |
|
HxLTBIRx |
Infectious Period Determination
Question |
Code |
Variable |
Date of infectious period beginning (format MM/DD/YY) -For symptomatic patients, start the infectious period 3 months before “Date of symptom onset” recorded on page 2. -For asymptomatic patients who have sputum smear-positive or cavitary disease, start the infectious period 3 months before the “Diagnosis date” recorded on page 2. -For asymptomatic patients without sputum smear-positive or cavitary disease, start the infectious period 1 month before the “Diagnosis date” recorded on page 2 |
|
IPopen
|
Date of infectious period end (format MM/DD/YY) For patients who are not isolated, the infectious period can be closed when the following three conditions are met:
For patients who are isolated (e.g. in a hospital) until these three conditions are met, then use date of isolation as the end of the infectious period. |
|
IPend
|
Public reporting burden of this collection of information is estimated to average 4 hours 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/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74 Atlanta, Georgia 30333; ATTN: PRA (0920-1011)
File Type | application/msword |
File Title | Contact Investigation |
Author | Derrick Felix |
Last Modified By | Eaton, Danice (CDC/OPHSS/CSELS) |
File Modified | 2016-05-05 |
File Created | 2016-05-05 |