CS347315-A (02/01/ CureTB Transnational Notification

CureTB Transnational Notification

OMB APPROVED CONTROL
NO 0920-1186
EXP DATE: 2/29/2024

Division of Global Migration Health | E-mail: [email protected] | Telephone: 619-542-4013
Web address: www.cdc.gov/cureTB

Referring Jurisdiction:

¹

Date sent:

¹

City County State
American
Alaska
Alabama
District
Delaware
Connecticut
Colorado
California
Arkansas
Arizona
Nevada
Nebraska
Montana
Missouri
Mississippi
Minnesota
Michigan
Massachusetts
Maryland
Maine
Louisiana
Kentucky
Kansas
Iowa
Indiana
Illinois
Idaho
Hawaii
Guam
Georgia
Florida
New
North
Northern
Puerto
Pennsylvania
Oregon
Oklahoma
Ohio
Rhode
South
U.S.
Virginia
Vermont
Utah
Texas
Tennessee
West
Washington
Wyoming
Wisconsin
Virgin
Hampshire
Jersey
Mexico
York
Virginia
Carolina
Dakota
Carolina
Dakota
Rico
Island
ofMariana
Columbia
Samoa
IslandsIslands

Contact person:

Telephone: Ext: Fax:

¹

¹

Referring Agency:

E-Mail Address:

Verified TB: RVCT:

Year Reported State

(9 digits/letters)

or

Not reported

ICE A#: BOP#:
Suspected TB

Clinical History request (specify year):

Immunocompromised (specify):

A. Patient

¹Name:

Paternal Maternal

First Middle

Sex: M F Alias:

DOB:

Email 1:

Email 2:

Check if patient/parent not currently at home. Current location: Telephone:
B. Info in U.S.

Address:

Street Apt City

American
Alaska
Alabama
District
Delaware
Connecticut
Colorado
California
Arkansas
Arizona
Nevada
Nebraska
Montana
Missouri
Mississippi
Minnesota
Michigan
Massachusetts
Maryland
Maine
Louisiana
Kentucky
Kansas
Iowa
Indiana
Illinois
Idaho
Hawaii
Guam
Georgia
Florida
New
North
Northern
Puerto
Pennsylvania
Oregon
Oklahoma
Ohio
Rhode
South
U.S.
Virginia
Vermont
Utah
Texas
Tennessee
West
Washington
Wyoming
Wisconsin
Virgin
Hampshire
Jersey
Mexico
York
Virginia
Carolina
Dakota
Carolina
Dakota
Rico
Island
ofMariana
Columbia
Samoa
IslandsIslands
County State

Home Phone: Cell:

Zip code

Contact person in the U.S.

Name:

Home Phone: Cell:

Relationship: Email:
C. Destination Country

Address:
Street

Apt City

County

Antigua
Angola
Andorra
Algeria
Albania
Afghanistan
Azerbaijan
Austria
Australia
Armenia
Argentina
Bosnia
Bolivia
Bhutan
Benin
Belize
Belgium
Belarus
Barbados
Bangladesh
Bahrain
Burkina
Bulgaria
Brunei
Brazil
Botswana
Cape
Canada
Cameroon
Cambodia
Burundi
Central
Comoros
Colombia
China
Chile
Chad
Congo,
Costa
Cote
Czech
Cyprus
Cuba
Croatia
Dominican
Dominica
Djibouti
Denmark
East
El
Egypt
Ecuador
Equatorial
The
Gabon
France
Finland
Fiji
Ethiopia
Estonia
Eritrea
Kiribati
Kenya
Kazakhstan
Jordan
Japan
Jamaica
Italy
Israel
Ireland
Iraq
Iran
Indonesia
India
Iceland
Hungary
Honduras
Haiti
Guyana
Guinea-Bissau
Guinea
Guatemala
Grenada
Greece
Ghana
Germany
Georgia
Korea,
Marshall
Malta
Mali
Maldives
Malaysia
Malawi
Madagascar
Macedonia
Luxembourg
Lithuania
Liechtenstein
Libya
Liberia
Lesotho
Lebanon
Latvia
Laos
Kyrgyzstan
Kuwait
Kosovo
Micronesia,
Mexico
Mauritius
Mauritania
Myanmar
Mozambique
Morocco
Montenegro
Mongolia
Monaco
Moldova
New
Netherlands
Nepal
Nauru
Namibia
Papua
Panama
Palau
Pakistan
Oman
Norway
Nigeria
Niger
Nicaragua
Rwanda
Russia
Romania
Qatar
Portugal
Poland
Philippines
Peru
Paraguay
Saint
San
Samoa
Sao
Saudi
Sierra
Seychelles
Serbia
Senegal
Solomon
Slovenia
Slovakia
Singapore
Somalia
South
Sri
Spain
Trinidad
Tonga
Togo
Thailand
Tanzania
Tajikistan
Taiwan
Syria
Switzerland
Sweden
Swaziland
Suriname
Sudan
Ukraine
Uganda
Tuvalu
Turkmenistan
Turkey
Tunisia
United
Vatican
Vanuatu
Uzbekistan
Uruguay
Zimbabwe
Zambia
Yemen
Vietnam
Venezuela
Salvador
Lanka
Bahamas
Gambia
Marino
Tome
Zealand
Timor
d’Ivoire
Kitts
Lucia
Vincent
Verde
Arabia
Rica
Africa
Sudan
Leone
Republic
Arab
Kingdom
States
New
North
South
and
African
Republic
Democratic
City
Faso
and
and
Islands
Islands
(Burma)
Guinea
and
and
Republic
(Timor-Leste)
Herzegovina
Federated
Guinea
Emirates
(Holy
Barbuda
Tobago
and
ofNevis
Principe
Republic
America
ofthe
See)
the
Republic
Grenadines
Statesofofthe
Zip code Country

State

Contact person at destination

Name:

Home Phone: Cell:

Relationship: Email:
D. Clinical Information

Information for:

this referred patient

Site(s) of disease: Pulmonary
HIV Diabetes

Other, specify:

Other(s), specify:

No Symptoms

Fields required to initiate the referral process
Please send imaging and laboratory reports as attachments
3
Please attach additional information, as needed
4
Please contact us via phone to confirm your referral was received
1
2

Symptoms, specify:
CS347315-A 02/01/2024

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 0920-1186

¹Name:

Paternal Maternal

First Middle

Sex: M F DOB:
Verified TB: RVCT:

Year Reported State

ICE A#:
Suspected TB

(9 digits/letters)

or

Not reported

BOP#:
Clinical History request (specify year):

Date of collection

Immunocompromised (specify):

Specimen type

2

Smear

2

Culture

2

Susceptibility

Other tests (specify):
Imaging

2

Date

Imaging

2

E. Medication

For:

this referred patient

Not started

Reason for not started:

Drug

Expected move date:

Dose

Patient given

Comments:

1
2
3

Fields required to initiate the referral process
Please send imaging and laboratory reports as attachments
Please attach additional information, as needed

days of medication.

Start date

Stop date