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| TB Indicator Data Reporting Form - 2017 |
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| Name of Panel Site & Country: |
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| Date of submission: |
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Instructions |
| Year data collected: January - December 2017 |
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2018 |
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How to enter repeat medical examinations:
►For an expired medical (e.g., person did not travel before expiraton date on DS form):
- Record the information from BOTH the first and second examinations as individual and separate events
►For a repeat examination at the completion of TB treatment:
- Record ONLY information from the initial examination where the applicant was assigned a Class A designation for TB. Do not record data from end-of-tx exam |
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TB Indicators for Each Calendar Month (2017) |
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| Indicator |
Jan. |
Feb. |
Mar. |
Apr. |
May |
June |
July |
Aug. |
Sept. |
Oct. |
Nov. |
Dec. |
TOTAL |
HELPFUL TIPS |
| 1. Number of Applicants Examined |
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ALL information for an applicant should only be entered into the column of the month in which the applicant was first examined. Example: an applicant is examined in April and must submit sputum; all the results of that sputum testing (including DST if performed) should be entered in the APRIL column even though the final results will not be available until June. |
1a. Total number of applicants examined
(ALL APPLICANTS OF ANY AGE) |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
Please ensure that Row 1a = 1b + 1c + 1d. |
| 1b. Number of Applicants ≥ 15 years old examined |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
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| 1c. Number of applicants 2-14 years old examined |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
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| 1d. Number of applicants < 2 years old examined |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
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| 2. Number with Sputum Required (TB Suspects) |
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| 2a. CXR Suggestive of TB |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
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| 2b. Signs & Sym. TB & Normal CXR (do NOT include positive TST or IGRA here) |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
Do not include children 2-14 years old who have positive TST or IGRA only. For TB Indicator reporting purposes, a positive TST or IGRA is not considered a "sign or symptom of TB." |
| 2c. HIV & Normal CXR & no Signs TB |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
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| 2d. TOTAL |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
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| 2e. TOTAL With Sputum Submitted (i.e. number of applicants who returned to complete TB testing requirements) |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
Should not be higher than value for 2d
0 |
Row 2e should be all applicants who have provided sputum specimens that have been submitted for processing (sputum culture results may still be pending at time of data submission). This number should not be higher than 2d. |
| 3. Non TB Mycobacteria |
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Section 3: Non-tuberculous mycobacteria (NTM) means that NTM was the lab result; it does not mean that the culture was completely negative for any organism. ONLY applicants with lab results that read "NTM" should be entered here. If an applicant was positive for BOTH NTM and MTB, enter the NTM results in this section and also in Section 5. |
| 3a. Smear+ /NTM+ |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
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| 3b. Smear- /NTM+ |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
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| 3c. TOTAL |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
If an applicant with cultures positive only for NTM (that is, the applicant does not have any cultures positive for MTB) requires treatment for the NTM for clinical reasons, please include that as a note at the bottom of the spreadsheet. |
| 4. Extrapulmonary TB Cases |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
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| 4a. Extrapulmonary TB Cases |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
An applicant who has been diagnosed with both pulmonary and extrapulmonary tuberculosis should be entered twice - once here as an extrapulmonary TB case (Section 4) and once as a pulmonary TB case (section 5). |
5. Pulmonary CLASS A TB Cases
(***IMPORTANT*** ONLY "Class A" TB cases undergoing TB treatment should be reported in Section 5; do NOT include B1 TB cases with smear-negative/culture- negative results here). |
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B1s should NOT be entered in this section; only applicants with pulmonary MTB should be entered in this section. Applicants positive for only NTM should not be entered in Section 5 unless they are alsopositive for pulmonary MTB. |
| 5a. Smear + / MTB Culture + |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
do not include NTM culture positive cases in Row 5a |
| 5b. Smear + / MTB Culture - |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
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| 5c. Smear - / MTB Culture + |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
do not include NTM culture positive cases in Row 5c |
| 5d. Smear - / MTB Culture - (do NOT include B1s here) |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
do not include smear negative/culture negative B1 cases in Row 5d |
| 5e. Smear+ /Culture Contamination |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
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| 5f. Smear- /Culture Contamination |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
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| 5g. TOTAL |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
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| 6. Drug Susceptibility Testing (DST) Results |
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| 6a. Pansusceptible |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
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| 6b. INH Monoresistance |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
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| 6c. RIF Monoresistance |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
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| 6d. MDR TB |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
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| 6e. XDR TB |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
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| 6f. Poly-resistance, not MDR or XDR TB |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
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| 6g. Monoresistant to drug other than INH/RIF |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
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| 6h. Unable to do DST due to NTM contamination (i.e., there was NTM overgrowth so that performing DST was not possible) |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
This row is for the very few individuals whose cultures were contaminated with NTM such that performing DST on the MTB was not possible. Please provide details in the notes section at the bottom of the spreadsheet if you include anyone in this line. |
| 6i. TOTAL |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
The total listed in row 6j should be the same as rows 5a + 5c |
| 7. Pulmonary TB Treatment |
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| 7a. DOT completed or in-progress at DGMQ-approved site |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
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| 7b. Declined DOT at DGMQ-approved site |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
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| 7c. TOTAL |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
The total listed in row 7c should be the same as row 5g |
| NOTES (please include any information here that you think may be helpful for CDC to have to interpret the information entered above or information about unique situations): |
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| Public reporting burden of this collection of information is estimated to average 7.5 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 Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-1102) |
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