CS347315-B (Revise CureTB Contact/Source Investigation (CI/SI) Notification

CureTB Contact/Source
Investigation (CI/SI) Notification

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

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

¹Referring Jurisdiction:

¹Date sent:
City

County

¹Contact person:

¹Telephone:

Referring Agency:

Ext:

Fax:

E-Mail Address:

Index Patient Information for:
¹Name:

Contact Investigation

Paternal

Source Investigation

Maternal

First

Number

Street

County

Apt

State

M

F

City

Home Phone:

Zip code

Cell:
Tel:

Check if patient/parent not currently home. Current location:
Contact person Name:
Relationship:

Sex:

Middle

Parent’s Name (if child for SI):

DOB or Age:

Alias:

A. Index Patient Information

State

Home Phone:

Cell:

E-Mail Address:

Clinical Information:
Site(s) of disease:
²Date of
collection

Pulmonary

Meningeal

²Specimen type

²Smear

Disseminated
Culture

Other(s), specify:
Treatment:

Susceptibility
Drug

Sens

Res

Start Date:

Comments:

INH
RIF
EMB
PZA

Primary Address of Exposure

Diabetes

No Symptoms

Symptoms,specify:

Address:
Telephone:

Country:
Name

DOB or
Age

Relationship to
index Patient

Date Last
Exposure

Risk Factors

Phone #
(H=Home; C=Cell)

≤5
y/o

HIV/
AIDS

Immunosuppression

Sx

On
Tx

Sx

On
Tx

Address:
Other Address of Exposure

B. Contacts/Possible Sources

HIV

Telephone:

Country:
Name

DOB or
Age

Relationship to
index Patient

Date Last
Exposure

Phone #
(H=Home; C=Cell)

Risk Factors
≤5
y/o

HIV/
AIDS

Immunosuppression

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.
4. Please contact us via phone to confirm your referral
was received

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

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Revised 01/2024 CS347315-B