0920-1238 EDN Tuberculosis Follow-Up Worksheet for Newly-Arrived P

Form approved

OMB Control No. 0920-1238 Expiration Date 03/31/2026

The EDN Tuberculosis Follow-Up Worksheet for Newly-Arrived Persons with Overseas Tuberculosis Classifications

A. Demographic

A1. Name (Last, First, Middle):

A2. Alien #:

A3. Visa type:

A4. Initial U.S. entry date:

A5. Age:

A6. Sex:

A7. DOB:

/ /

A8. TB Class Based on Technical Instructions for Panel Physicians:

A9. Country of examination:

A10. Country of birth:

A11a. Name in care of:

A11b. Phone number: A11c. Address:

A12a. Sponsor agency name:

A12b. Phone number: A12c. Address:

B. Jurisdictional Information

B1. Arrival jurisdiction: B2. Current jurisdiction:

C. U.S. Evaluation

C1. Date of first U.S. test or provider/clinic visit: / /

Mantoux Tuberculin Skin Test (TST) in U.S.

Interferon-Gamma Release Assay (IGRA) in U.S.

C2a. Was a TST administered in the U.S.?

^{Yes No} Unknown

If YES, ^{C2b. TST placement date: / /}

Placement date unknown

C2c. TST mm: ^Unknown C2d. TST interpretation:

^Positive Negative Unknown

C2e. History of Previous Positive TST:

^{Yes No} Unknown

C3a. Was IGRA performed in the U.S.? ^{Yes No Unknown}

^{If YES, C3b. Date collected:} / / ^{Date unknown}

IUs/Spots

C3c. IGRA brand:

QuantiFERON® ^T-SPOT Other, specify:

^{C3d. Result:} Positive Negative Indeterminate,

Borderline, or

Invalid ^{Unknown Equivocal}

C3e. History of previous positive IGRA:

^{Yes No} Unknown

U.S Review of Pre-Immigration/I-693 CXR

U.S. Domestic CXR

Comparison

C4. Pre-immigration CXR/I-693 available?

Yes No Unknown

C6a. U.S. domestic CXR done? Yes No Unknown

If YES, C6b. Date of U.S. CXR: / /

C8. U.S. domestic CXR comparison to pre-immigration/I-693 CXR:

Stable Worsening Improving Unknown

C5. U.S. interpretation of pre-immigration/I-693 CXR:

Normal (Negative for TB) Abnormal

Suggestive of TB Non-TB Condition

Poor Quality/Not Interpretable

Unknown

C7. Interpretation of U.S. CXR:

Normal (Negative for TB) Abnormal

Suggestive of TB Non-TB Condition

Poor Quality/Not Interpretable

Unknown

Public reporting burden of this collection of information is estimated to average 30 minutes per individual, 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 Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-1238).

^{C9a. Completed treatment pre-immigration/I-693?} Yes No

Unknown

^{If YES, C9b.} Treated for TB disease Treated for LTBI Treated, but unknown if TB disease or LTBI

If Treated for TB disease,

Treatment completed prior to panel physician or civil surgeon examination Treatment completed after panel physician or civil surgeon diagnosis (DS 3030)

At DGMQ-designated DOT site

At non-DGMQ-designated DOT site

Other, specify:

C9c. Treatment start date: / / ^{Start date unknown} C9d. Treatment end date: / / _{End date unknown}

C9e. Report of treatment administered prior to panel physician or civil surgeon examination:

Treatment documented on overseas medical history form (DS 3026)

Documented on DS forms & patient reported at panel physician or civil surgeon examination

After U.S. arrival only, patient verbally reported treatment completion

Unknown

The EDN Tuberculosis Follow-Up Worksheet for Newly-Arrived Persons with Overseas Tuberculosis Classifications

Alien #

U.S. Review of Pre-Immigration/I-963 Treatment

C9f. Standard TB treatment regimen was administered?

Standard TB treatment Non-standard TB treatment

Unable to verify

C10a. Arrived to the U.S. on treatment?

Yes No Unknown

If YES, C10b. Treated for TB disease ^{Treated for LTBI}

C10c. Start date: / / ^{Start date unknown} C11a: Pre-Immigration/I-693 treatment concerns?

Yes No

If YES, C11b. Select all that apply: Treatment duration too short Incorrect treatment regimen

Inadequate information provided

Lack of adequate diagnostics Unknown DOT/adherence status Undocumented/unverified treatment

Other, specify:

^{C12. U.S. Microscopy/Bacteriology*} _{Sputa collected in U.S.? Yes} No *Covers all results regardless of sputa collection method.

#

Date Collected

AFB Smear

Sputum Culture

Drug Susceptibility Testing

1

/ /

^Positive Negative

^{Not Done} Unknown

NTM

Contaminated Not Done

MTB Complex Negative Unknown

MDR-TB

Mono-INH No DR

Mono-RIF Other DR Not Done

2

/ /

Positive _Negative

^{Not Done} Unknown

NTM

Contaminated Not Done

MTB Complex Negative Unknown

MDR-TB

Mono-INH No DR

Mono-RIF Other DR Not Done

3

/ /

Positive Negative

Not Done Unknown

NTM MTB Complex

Contaminated Negative

Not Done Unknown

^MDR-TB Mono-RIF

Mono-INH Other DR

^{No DR} Not Done

D. Evaluation Disposition in U.S.

^{D1a. Evaluation disposition date in U.S.: / /} D1b. State/jurisdiction of evaluation disposition in U.S.:

D2a. Evaluation disposition in U.S.:

Completed evaluation

D2b. If evaluation was completed, was treatment recommended?

Yes ^No

LTBI

Active TB

Initiated Evaluation / Not completed Did not initiate evaluation

D2c. If evaluation was NOT completed, why not? Select all that apply.

Not Located ^{Moved within U.S., transferred to:}

State/jurisdiction

Lost to Follow-Up Moved outside U.S.

^{Refused Evaluation} Died

^Unknown Other, specify:

D3. Diagnosis Class 0 - No TB exposure, not infected or Class 1 - TB exposure, no evidence of infection

Class 2 - TB infection, no disease ^{Class 3 - TB, TB disease}

^{Class 4 - TB, inactive disease Pulmonary} Extra-pulmonary ^{Both sites}

^{Culture-confirmed} Yes ^No

The EDN Tuberculosis Follow-Up Worksheet for Newly-Arrived Persons with Overseas Tuberculosis Classifications

Alien #

^D4. If diagnosed with TB disease:

State Case Number:

^{RVCT # unknown*} RVCT Reported* Year ^State _{RVCT # / TBLISS #}

_{TBLISS # unknown*} TBLISS Reported*

City/County Case Number:

Year State RVCT # / TBLISS #

*Note: Either the RVCT or TBLISS number may be reported.

E. U.S. Treatment for TB Disease or TB Infection

^{E1a. U.S. treatment initiated:} Yes No Unknown

E1b. If NO, specify the reason. Select all that apply:

Patient declined against medical advice Lost to follow-up ^{Moved within U.S., transferred to:}

State/jurisdiction

^{Died Moved outside the U.S.} Prior treatment completed (year: )

^{Currently on treatment} Treatment not offered based on Unknown

Contraindication for treatment ^{local clinic guidelines} _{Other, specify:}

^{E1c. If YES: Treated for TB disease} Treated for LTBI

E2. Treatment start date: / / ^{E3. State/jurisdiction of treatment in U.S.:}

E4. Specify initial LTBI regimen: Isoniazid (9 months; 9H) Isoniazid (6 months; 6H)

Isoniazid/Rifapentine (3 months; 3HP) Isoniazid/Rifampin (INH+RIF; 4 months) Rifampin (4 months; 4R)

Isoniazid/Rifampin/Ethambutol/Pyrazinamide (RIPE; 2 months; suspected TB disease) Unknown

Other, specify:

E5a. U.S. treatment completion status* and dates: ^{Completed / / Treatment ongoing}

^{Treatment discontinued/stopped / /} Unknown

*Completed refers to finished treatment, Treatment ongoing refers to treatment that is initiated but not yet completed. Treatment discontinued/stopped refers to initiated treatment that is not completed.

If treatment discontinued/stopped, E5b. Specify the reason. Select all that apply:

Patient declined against medical advice _{Lost to follow-up} ^{Moved within U.S., transferred to:}

_{Died Unknown} ^State/ jurisdiction

Moved outside the U.S.

Dying (treatment stopped because _{Adverse effect Other, specify:}

of imminent death, regardless of cause

_{of death) Not TB disease} Developed TB [For

_{Provider decision Pregnancy [For patient} patient diagnosed with

diagnosed with LTBI] ^LTBI]

F. Evaluation Site Information

G. Treatment Site Information

Provider’s Name: Clinic Name: Telephone Number:

Provider’s Name:

Clinic Name:

Telephone Number:

Same as evaluation site information

H. Comments

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