OMB Control No: 0970-0466
Expiration date: XX/XX/XXXX
Supplemental Form: TB Screening Unaccompanied Children’s Program Office of Refugee Resettlement (ORR) |
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General Information (to be completed by program staff) |
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Child
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Last name: |
First name:
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DOB:
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A#:
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Gender: |
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Healthcare Provider or Health Dept. |
Name:
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Phone number:
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Clinic/Practice:
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Street address:
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City/Town: |
State: |
Date of visit:
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Program |
Name of program staff with child: |
Program name:
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Medical Information (to be completed by healthcare provider’s office or health department) |
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PPD/Tuberculin skin test (TST): |
Date applied: ____ / ____ / ______ |
Date read:____ / ____ / ______ |
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Result: ________ mm |
Interpretation: |
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TB blood test (Interferon-Gamma Release Assay [IGRA]): |
Date drawn: ____ / ____ / _____ |
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Test Type: |
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Result: |
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Chest x-ray: |
Date: ____ / ____ / _____ |
Findings: |
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TB Screening Outcome |
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Bacteriologic Results |
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Collection Date |
Specimen Type (e.g., Sputum) |
Test Type (e.g., AFB smear) |
Result |
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Special Requirements for Release |
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If the child had been AFB smear positive, list the dates of the 3 consecutive negative AFB smears: |
#1: |
#2: |
#3: |
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If the TB culture was positive and the DST was MDR or XDR, list the dates of the 2 subsequent negative cultures: |
#1: |
#2: |
THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) Public reporting burden for this collection of information is estimated to average 3 minutes per response, including the time for reviewing instructions, gathering and maintaining the data needed, 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.
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File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Buckley, Kirsten (CDC/OID/NCEZID) |
File Modified | 0000-00-00 |
File Created | 2021-01-14 |