DS-3030 Tuberculosis Worksheet

OMB No. 1405-0113
EXPIRATION DATE: XX/XX/XXXX
ESTIMATED BURDEN: 15 MINUTES
(See Page 2 - Back of Form)

U.S. Department of State

TUBERCULOSIS WORKSHEET
Surnames

Photo

Birth Date (mm-dd-yyyy)

Given Names

Document Type

Age
Document Number

Case or Alien Number

1. Test for Cell-Mediated Immunity to Tuberculosis
See Tuberculosis Technical Instructions, when required, perform one type only, and attach results
IGRA performed, mark which test:
QuantiFERON
T-Spot
Date drawn (mm-dd-yyyy)
Positive
Negative
Indeterminate, Borderline, or Equivocal

QuantiFERON (indicate optimal density value
[IU/ml] for each)

T-Spot (indicate spot count for each)

Nil Control:

Nil Control:

TB Antigen1:

Panel A:

TB Antigen2:

Panel B:

Mitogen:

Positive Control:

2. Chest X-Ray Indication (Mark all that apply)
Chest X-Ray not indicated
Age > 15 years

Extrapulmonary tuberculosis

Known HIV infection

History of Tuberculosis

Signs or symptoms of tuberculosis

IGRA positive

Date Chest X-Ray Taken
(mm-dd-yyyy)

3. Chest X-Ray Findings (for radiologist to complete all of Section 3)
Normal Findings
Abnormal Findings (Indicate category and finding, marking all that apply in the tables below)
Does Not Need Smears and Cultures
Suggests Tuberculosis (Need Smears and Cultures)
Miliary findings
Mark as Class B
Do Not Mark as Class B
Infiltrate or consolidation
Other on DS-2054
Other on DS-2054
Reticular markings suggestive of fibrosis
Discrete linear opacity
Cavitary lesion

Discrete nodule(s) without calcification

Nodule(s) or mass with poorly defined
margins (such as tuberculoma)
Pleural effusion

Volume loss or retraction

Cardiac
Musculoskeletal

Irregular thick pleural reaction
Other

Other, specify in
Remarks

Hilar/mediastinal adenopathy

Smooth pleural thickening (if at CPA,
must confirm is not effusion [do lateral
or decubitus radiograph or ultrasound])
Diaphragmatic tenting
Single or scattered calcified pulmonary
nodule(s)
Calcified lymph node(s)

Radiologist's Remarks

Radiologist's Name (Printed)

Radiologist's Signature (Required)

Date Interpreted (mm-dd-yyyy)

4. Sputum Smears and Cultures Decisions
No, not indicated -Applicant has no signs or symptoms of TB, no known HIV infection, and:
X-ray Normal or 'No specimens required' and test for cell-mediated immunity to TB negative (if performed)
X-ray Normal or 'No specimens required' and test for cell-mediated immunity to TB positive (if performed)
Yes, are indicated - Applicant has (Mark all that apply):
Signs or symptoms of TB

Extrapulmonary TB

Chest X-ray suggests TB

End of treatment cultures

Known HIV Infection
5. Sputum Smears and Cultures Results

Sputum
Smear
Results

Date specimen obtained
(mm-dd-yyyy)

Date smear result reported
(mm-dd-yyyy)

Positive

Negative

Positive

Negative

1.
2.
3.

Sputum
Culture
Results

Date specimen obtained
Date culture result reported (mm-dd-yyyy)
(mm-dd-yyyy)
*Use most recent date as date of exam on DS-2054

NTM

Contaminated

1.
2.
3.

DS-3030
09-2020

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6. Tuberculosis Classification
Applicants can be both Class B1 and Class B3, or Class B2 and Class B3. However, other combinations of tuberculosis classifications are not
permitted.
No TB Classification
CXR not suggestive of tuberculosis, no tuberculosis signs or symptoms, no known HIV infection, TST or IGRA negative (if performed), not a
contact
Class A
Applicant has tuberculosis disease
Class B0, TB, Pulmonary
Diagnosed with tuberculosis by the panel physician or presented to the panel physician while on tuberculosis treatment and successfully
completed DGMQ-defined DOT
Class B1 TB, Pulmonary
CXR suggests tuberculosis, or tuberculosis signs and symptoms, or known HIV infection and sputum smears and cultures are negative and
not a clinically diagnosed case.
Class B1 TB, Extrapulmonary
Applicants with evidence of extrapulmonary tuberculosis. The anatomic site of infection should be documented.
Anatomic Site of Disease
No treatment
Current treatment
Completed treatment
Started but did not finish extrapulmonary treatment
Class B2 TB, LTBI Evaluation
Applicants who have a tuberculin skin test > 10 mm or positive IGRA but otherwise have a negative evaluation for tuberculosis. Contacts with
TST > 5 mm or positive IGRA should receive this classification (if they are not already Class B1 TB, Pulmonary).
No LTBI treatment
If treated, LTBI treatment:
Current LTBI treatment
LTBI treatment by panel physician
Completed LTBI treatment
LTBI treatment by non-panel physician
Started but did not finish LTBI treatment
Dates of treatment
to
Class B3 TB, Contact Evaluation
Applicants who are a recent contact of a known tuberculosis case.
No preventive treatment
Window Prophylaxis
Isoniazid
Rifampin

3HP

Other

If treated, mark LTBI regimen:
Isoniazid
Rifampin
3HP
Other

Dates of treatment

to

Source Case:
Name
Case or Alien Number, if known
Relationship to Contact
Date Contact Ended (mm-dd-yyyy)
Type of Source Case TB (Mark only one and attach DST results)
Pansusceptible TB
MDR TB (resistant to at least INH and rifampin)
Drug-resistant TB other than MDR TB
Culture negative
Culture results not available
DST results not yet available
Remarks

DS-3030

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7. History of Class A TB
Complete this section only if one of the following is true (mark appropriate option):
Applicant was previously diagnosed with Class A TB by the panel physician
Applicant was on tuberculosis treatment at the time of presentation for their medical examination
How was the diagnosis made:

Positive laboratory tests

Clinical diagnosis

Diagnostic Chest Radiograph
Facility performing chest radiograph:
Date Radiograph obtained (mm-dd-yyyy):
Findings Present
Normal or no findings suggestive of tuberculosis

Hilar/mediastinal adenopathy

Infiltrate or consolidation

Miliary findings

Reticular marking suggestive of fibrosis

Discrete linear opacity

Cavitary lesion

Discrete nodule(s) without calcification

Nodule(s) or mass with poorly defined margins (such as
tuberculoma)
Pleural effusion

Volume loss or retraction
Irregular thick pleural reaction
Other

Sputum Smear Result at Diagnosis
Date specimen obtained
(mm-dd-yyyy)

Date results reported
(mm-dd-yyyy)

Positive

Negative

Date results reported
(mm-dd-yyyy)

Positive

Negative

1.
2.
3.

Sputum Culture Result at Diagnosis
Date specimen obtained
(mm-dd-yyyy)

NTM

Contaminated

1.
2.
3.

Drug Susceptibility Test Results
Date specimen obtained
(mm-dd-yyyy)

Method of DST:
MGIT

Agar

LJ
Drug

Required for
first-line DST

Required for
multidrugresistant
cases

Date DST reported
(mm-dd-yyyy)

Susceptible

Resistant

Isoniazid
Rifampin
Ethambutol
Pyrazinamide
Ethionamide
Amikacin
Capreomycin
Para-aminosalicylic acid (PAS)
Fluoroquinolone, specify:
Other, specify:

DS-3030

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7. History of Class A TB, Continued
Were molecular tests used in addition to the required sputum smears, cultures, and DST:
No
Yes (mark all that apply):

Molecular Test

Mycobacterium
Rifampin
Isoniazid
Tuberculosis
Resistance
Resistance
Positive Negative Positive Negative Positive Negative

Hain Line Probe Assay

Performed, attach results

GeneXpert

Performed, attach results

Other

Performed, attach results

Tuberculosis Treatment
Treating physician or institution
Approved DOT site:
Unapproved TB treatment site:
Drug

Dosage

Start Date (mm-dd-yyyy)

End Date (mm-dd-yyyy)

Isoniazid
Rifampin
Ethambutol
Pyrazinamide
Other, specify:

PAPERWORK REDUCTION ACT AND CONFIDENTIALITY STATEMENTS
PAPERWORK REDUCTION ACT
STATEMENT
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DS-3030

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