Minimum Inhibitory Concentration Report Form

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

Att. 9-MIC Results Form

Minimum Inhibitory Concentration Reports

OMB: 0920-0600

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

Attachment 9


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







































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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:







File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorYakrus, Mitchell (CDC/OID/NCHHSTP)
File Modified0000-00-00
File Created2021-01-20

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