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) |
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Contact’s Relationship to Index: |
Date of Last Exposure: _____/_____/_____ |
Location of Exposure: |
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Number of days per week: Number of hours per day: |
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Number of days per week: Number of hours per day: |
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Number of days per week: Number of hours per day: |
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Yes (If Yes, person is automatically a close contact)
No |
IF YES, specify type of procedure(s) and date(s)
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Yes No |
TB Symptom Screening (Current Symptoms) |
Start Date and Duration |
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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 |
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Yes No |
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Yes No |
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Yes No |
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Yes No |
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Yes No |
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Yes No |
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Yes No |
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Yes No Unknown |
If yes, how much? |
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Yes No
If yes, specify symptom start date: ____/____/_____
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TB Risk Factor Screening |
Notes |
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Instructions: Screen to see if the contact has risk factors that could increase their risk for progression to active TB disease. |
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Yes No |
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Yes No |
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Yes No or Unknown |
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Yes No or Unknown |
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Yes No or Unknown |
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Yes No |
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Yes No |
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Yes No |
If yes, specify amount/frequency
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Yes No |
If yes, include types/routes, frequency, and locations where substances acquired and used
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Yes No |
Additional Questions |
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If yes, what was/is the nature of your relationship and contact?
What did/does this person do during
the day?
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END QUESTIONS
Test Results |
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Date TST Placed |
Date TST Read |
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Chest X-Ray |
TST 1: |
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CXR Date: _____/_____/_____
CXR Result: Not Suggestive of TB Suggestive of TB |
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TST 2: |
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TST Interpretation: Negative Positive If pos, Conversion? |
Test Results |
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Date of IGRA |
IGRA Result |
Chest X-Ray |
IGRA 1: |
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CXR Date: _____/_____/_____
CXR Result: Not Suggestive of TB Suggestive of TB |
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IGRA 2: |
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IGRA Interpretation: Negative Positive If pos, Conversion? |
Treatment |
Rx Start Date: _____/_____/_____
Rx End Date: _____/_____/_____
Rx Regimen:
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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 |
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)
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 |