CureTB Transnational Notification

OMB APPROVED CONTROL
NO 0920-1186 EXP DATE:
06/30/2020

CureTB Transnational Notification

\

Division of Global Migration and Quarantine | E-mail: [email protected] | Telephone: 619-542-4013 |
Fax For California: 619-692-8020 | Fax For other areas: 404-471-8905 | Web address: www.cdc.gov/usmexicohealth/curetb.html

¹Referring Jurisdiction:

_______
City

County

¹Date sent: _______

State

¹Contact person:

¹Telephone:

Referring Agency:

Ext.

Fax:

___ E-Mail Address:

Verified TB:

RVCT#:

Year reported

-

or

State

Not reported

(9 digits/letters)

ICE A#

BOP#

Suspected TB

-

Clinical History request (specify year):

Immunocompromised (specify): _________________________

¹Name: ________

__ Sex:

B. Info in U.S.

A. Patient

Paternal

Maternal

Alias:

C. Destination Country

First

M

F

Middle

DOB: _____________ E-Mail:

Check if patient/parent not currently at home. Current location:

Number

Tel.:

Street

County

Apt

State

City

Home Phone:

Cell:

Home Phone:

Cell:

Zip code

Contact person in the U.S.: Name:
Relationship:

E-Mail:

Number

Street

Apt

City

Country:
County

State

Zip code

State: __________________________

Contact person at destination: Name:

Home Phone:

Relationship:

E-Mail:

Information for:

this referred patient

Site (s) of disease:

Pulmonary

HIV

D. Clinical Information

Page1

2Date

Diabetes

Other, specify:

Other (s) specify:

No Symptoms

of collection

Cell:

2Specimen

Symptoms, specify: ________________________________________________________
type

2Smear

Culture

Susceptibility

Other tests (specify): _____________________________________________________________________________________________
________________________________________________________________________________________________________________
1 Fields required to initiate the referral process
2. Please send imaging and laboratory reports as attachments
3. Please attach additional information, as needed
REVISED 10/2019

Public reporting burden of this collection of information is estimated to average 30 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:
PRA 0920-XXXX

CureTB Transnational Notification

OMB Approved
Control No
0920-XXXX
Exp Date:
XX/XX/XXXX

Centers for Disease Control and Prevention
Division of Global Migration and Quarantine
E-Mail: [email protected]

Telephone: (619) 542-4013
Fax: (404) 471-8905
Page 2

Name:

Sex:

Verified TB:

RVCT#:

Year reported

State

ICE A#

or

F

Not reported

(9 digits/letters)

BOP#

Suspected TB

M

Clinical History request (specify year):

-

Immunocompromised (specify): _________________________

2Imaging

2Imaging

Date

For:

this referred patient

Dose

Start date

Stop date

E. Medication

Drug

Not started Reason for not started: _________________________________________________

Expected move date: _____________________________ Patient given

days of medication.

Comments:

1 Fields required to initiate the referral process
2. Please send imaging and laboratory reports as
attachments
3. Please attach additional information, as needed
REVISED 10/2019

Public reporting burden of this collection of information is estimated to average 30 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:
PRA 0920-XXXX