Form 16AWE Attachment D CureTB_Transnational_Notification_CureTB 07

OMB Approved

Control No 0920-XXXX

Exp Date: XX/XX/XXXX

C ureTB Transnational Notification

Centers for Disease Control and Prevention

Division of Global Migration and Quarantine

E-Mail: [email protected]

Telephone: (619) 542-4013 Fax: (404) 471-8905

¹Referring Jurisdiction: ¹Date sent:

City County State

¹Contact person: ¹Telephone: Ext. Fax:

Referring Agency: E-Mail Address:

Verified TB: RVCT#: or Not reported ICE A# BOP#

Suspected TB Clinical History request (specify year): Immunocompromised (specify): _________________________

Patient

¹Name: Sex: M F

^{Paternal Maternal First Middle}

Alias: DOB: _____________ E-Mail:

Check if patient/parent not currently at home. Current location: Tel.:

Info. in U.S.

^{Number Street Apt City}

Home Phone: Cell:

^{County State Zip code}

Contact person in the U.S.: Name: Home Phone: Cell:

Relationship:

Destination Country

^{Number Street Apt City}

Country:

^{County State Zip code}

Contact person at destination: Name: Home Phone: Cell:

Relationship: Home Phone: Cell:

Clinical Information

Information for: this referred patient Other, specify:

Site (s) of disease: Pulmonary Other (s) specify:

HIV Diabetes No Symptoms Symptoms, specify: ________________________________________________________

2Date of collection	2Specimen type	2Smear	Culture	Susceptibility	Date	2Imaging

Comments:

Medication

Other tests (specify): _______________________________________________________________________________________________

Public reporting burden of this collection of information is estimated to average 30 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-XXXX

For: this referred patient Not started

Drug	Dose	Start date	Stop date

Expected move date: _____________________________

Patient given days of medication.

File Type	application/vnd.openxmlformats-officedocument.wordprocessingml.document
File Title	Binational Notification Form
Author	Alberto Colorado
File Modified	0000-00-00
File Created	2021-01-22