Minimum Inhibitory Concentration Report Form

CDC Model Performance Evaluation Program (MPEP) for Mycobacterium tuberculosis Drug Susceptibility Testing

Attachment 9

MPEP Mycobacterium. tuberculosis Minimum Inhibitory Concentration (MIC) Results Form

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: OMB-PRA (0920-0600)

MPEP Mycobacterium tuberculosis Minimum Inhibitory Concentration (MIC) Results Form

Enter your minimum inhibitory concentration and drug susceptibility test result interpretation for each isolate tested by Sensititre by using the data worksheet below. Please complete one worksheet per isolate in addition to the online data entry. For laboratories who customize Sensititre plates, please use ‘Other’ for any additional antituberculosis drugs tested.

Completed worksheets should be emailed to [email protected] prior to the submission deadline.

MPEP Number                     

Isolate      

Drug	MIC	Resistant	Susceptible	Borderline	Contaminated	No Growth	Not Done
Rifampin
Isoniazid
Ethambutol
Streptomycin
Ofloxacin
Ciprofloxacin
Moxifloxacin
Levofloxacin
Amikacin
Kanamycin
Capreomycin
Ethionamide
Rifabutin
Cycloserine
Para-Amino Salicyclic Acid
Other:
Other:
Other: