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| TB Indicator Data Reporting Form - 2018 |
| Name of Panel Site & Country: |
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| Date of submission: |
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| Year data collected: January - December 2018 |
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TB Indicators for Each Calendar Month (2018) |
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| Indicator |
Jan. |
Feb. |
Mar. |
Apr. |
May |
June |
July |
Aug. |
Sept. |
Oct. |
Nov. |
Dec. |
TOTAL |
| 1. Number of Applicants Examined |
|
|
1a. Total number of applicants examined
(ALL APPLICANTS OF ANY AGE: 1b + 1c + 1d) |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
| 1b. Number of Applicants ≥ 15 years old examined |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
| 1c. Number of applicants 2-14 years old examined |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
| 1d. Number of applicants < 2 years old examined |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
| 2. Number with Sputum Required (TB Suspects) |
|
|
| 2a. Abnormal CXR Suggestive of TB |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
| 2b. Normal CXR with signs/symptoms TB (do NOT include positive TST/IGRA here) |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
| 2c. Known HIV infection (w/Normal CXR & no Signs TB) |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
| 2d. TOTAL |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
| 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 |
0 |
| 3. Non TB Mycobacteria |
|
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| 3a. Smear+ /NTM+ |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
| 3b. Smear- /NTM+ |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
| 3c. TOTAL |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
| 4. Extrapulmonary TB Cases |
|
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| 4a. Extrapulmonary TB Cases |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
5. Pulmonary CLASS A TB Cases ONLY
|
Russell, Michelle (CDC/OID/NCEZID):
Moved this text from column A
***IMPORTANT*** ONLY "Class A" TB cases undergoing TB treatment should be reported in Section 5; DO NOT include B1 TB cases with smear- / culture- results here |
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| 5a. Smear + / MTB Culture + |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
| 5b. Smear + / MTB Culture - |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
| 5c. Smear - / MTB Culture + |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
| 5d. Smear - / MTB Culture - (do NOT include B1s here) |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
| 5e. Smear+ /Culture Contamination |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
| 5f. Smear- /Culture Contamination |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
| 5g. TOTAL |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
| 6. Drug Susceptibility Testing (DST) Results |
Russell, Michelle (CDC/OID/NCEZID):
Moved this text from Column A
**NOTE: DST results are required for all culutre positive isolates per CDC's TB Technical Instructions
Total in Row 6i should equal Row 5a + 5c |
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| 6a. Pansusceptible |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
| 6b. INH Monoresistance |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
| 6c. RIF Monoresistance |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
| 6d. MDR TB |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
| 6e. XDR TB |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
| 6f. Poly-resistance, not MDR or XDR TB |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
| 6g. Monoresistant to drug other than INH/RIF |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
| 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 |
| 6i. TOTAL |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
| 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 |
| 7b. Declined DOT at DGMQ-approved site |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
| 7c. TOTAL |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
| 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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