Contact Interview and Abstraction Form

Form Approved

OMB No. 0920-1011

Exp. Date 03/31/2017

Tuberculosis Contact Screening Form

Contact Name:	 Male  Female	DOB: _____/_____/_____	Age:
Current Location:

Contact Exposure History (During the Infectious Period)
Contact’s Relationship to Index:	Date of Last Exposure: _____/_____/_____
Location of Exposure:
How much time did you spend in the same room or house as the index while he/she was contagious (during the infectious period)?	Number of days per week: Number of hours per day:
How much time did you spend in a bar or drug-using location as the index while he/she was contagious (during the infectious period)?	Number of days per week: Number of hours per day:
How much time did you spend in the same room in the hospital while he/she was contagious (during the infectious period)?	Number of days per week: Number of hours per day:
If you are a healthcare worker, did you perform any procedures on the index patient that may have caused them to cough (such as suctioning, collecting sputum, performing CPR, using a bag mask, or intubation)	Yes (If Yes, person is automatically a close contact) No
IF YES, specify type of procedure(s) and date(s)
Specify other contact setting and any related details
Based upon the answers above, is this a “close” contact? A “close” contact is a person who spent ≥4 hours multiple times or spent ≥8 hours at least one time inside the same room as the index patient (during the infectious period)?	Yes No

TB Symptom Screening (Current Symptoms)		Start Date and Duration
Instructions: Screen to see if the contact currently has TB symptoms. Consider the contact “symptomatic for TB” if they have: (1) A cough for ≥2 weeks duration OR (2) Two “yes” responses to symptoms #2-8 that cannot be explained by another medical condition
Have you been coughing for ≥2 weeks?	Yes No
Have you been coughing up blood?	Yes No

Have you had difficulty breathing?	Yes No
Have you had fevers or chills?	Yes No
Have you had night sweats? (completely soaking your clothes at night)	Yes No
Have you been tired or feeling weak lately?	Yes No
Have you lost your appetite?	Yes No
Have you had unplanned weight loss?	Yes No Unknown		If yes, how much?
Is this contact symptomatic for TB?	Yes No If yes, specify symptom start date: ____/____/_____
TB Risk Factor Screening				Notes
Instructions: Screen to see if the contact has risk factors that could increase their risk for progression to active TB disease.
Is this contact >50 years old?		Yes No
Was this contact <5 years old during the exposure period?		Yes No
Do you have diabetes?		Yes No or Unknown
Do you have HIV?		Yes No or Unknown
Do you have cancer?		Yes No or Unknown
Do you take prednisone every day?		Yes No
Do you smoke tobacco?		Yes No
Do you drink alcohol?		Yes No		If yes, specify amount/frequency
Do you use any other substances?		Yes No		If yes, include types/routes, frequency, and locations where substances acquired and used
Does this contact have a high-risk condition? If the contact answers “yes” to questions 1-6 above, then the contact has a high-risk condition.				Yes No

Additional Questions

1. Have you ever been diagnosed with active TB disease?
   If so, please provide details including treatment if any.

2. Have you ever been diagnosed with latent TB infection?
   If so, please provide details including treatment if any.

3. Have you ever known anybody with TB?

If yes, what was/is the nature of your relationship and contact?

What did/does this person do during the day?
How did/does he/she spend his/her time?
Who spent/spends a lot of time with that person?

4. Do you know anybody now who might have TB symptoms?
   (e.g., cough ≥2 weeks, fevers, chills, unintended weight loss)

END QUESTIONS

Test Results		Date TST Placed	Date TST Read	MM	Chest X-Ray
	TST 1:				CXR Date: _____/_____/_____ CXR Result:  Not Suggestive of TB  Suggestive of TB
	TST 2:
	TST Interpretation:  Negative  Positive If pos, Conversion? 

Test Results		Date of IGRA	IGRA Result	Chest X-Ray
	IGRA 1:			CXR Date: _____/_____/_____ CXR Result:  Not Suggestive of TB  Suggestive of TB
	IGRA 2:
	IGRA Interpretation:  Negative  Positive If pos, Conversion? 

Treatment

Rx Start Date: _____/_____/_____ Rx End Date: _____/_____/_____ Rx Regimen:

Treatment Outcome

 Completed LTBI treatment  Provider decision to stop  Adverse effects of medicine  Moved  Lost to follow-up  Died  Refused treatment  Other (specify): ____________

TB Status

 LTBI  TB Disease  Not infected (test negative 8 weeks after last exposure)  Lost to
follow-up

Interviewer Name: __________________________ Date: _____/_____/_____

Public reporting burden of this collection of information is estimated to average 15 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/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74 Atlanta, Georgia 30333; ATTN: PRA (0920-1011)