Form 0920-1071-24AU TB Care Finder info requested to TB control programs PRA

Form Approved

OMB Control No.: 0920-1071

Expiration date: 5/31/2024

TB Care Finder data collection instrument

1. Requesting a Jurisdiction

   1. Are you requesting permission to edit guidance for a state, region or county, city, tribal area? “Region” include districts, counties, parishes (LA), municipalities (PR), and boroughs (AK). If you are using TB Care Finder as a regional health department, please see the job aid for further instructions.

   2. Please enter the state or territory to which this TB guidance applies. Write names and not abbreviate. e.g., “California” or “Rhode Island” or “Puerto Rico.”

   3. Please enter the counties to which this TB guidance applies. County names must be separated by commas and include the full county name: e.g., “San Diego County, Riverside County.” If you are not entering county-level information, please leave this field blank.

2. General contact information

   1. TB Program name

   2. Address

   3. City

   4. State

   5. Zip Code

   6. Phone

   7. Email

   8. Website URL

      1. Add a Spanish website URL, if available.

   9. PDF documents: If you would like to upload a PDF document, for example, to provide entrants additional information about their first visits (e.g., standard letter or FAQs), we suggest files smaller than 500 KB.

   10. Map information: If you would like to add a map of your health department location to your page, please enter the latitude and longitude below. You can find the latitude and longitude here.

       1. Health Department Latitude

       2. Health Department Longitude

   11. Please enter any additional comments you would like to share about your health department’s TB program.

       1. Add a Spanish translation of your TB program comments, if available.

3. Receive regular emails remainders to update your information: You have the option to set email remainders to check your program’s information in the directory.

   1. Please provide a group email address; CDC does not permit personal emails. After you get the reminder, program the next reminder in this form.

      1. Please enter reminder date for your update.

      2. Group email address

4. Offer more TB program information: On your jurisdiction’s resource page, you have the option to provide answers to the following questions. All free-text responses are optional, answers left blank will not display questions in your page.

   1. Services for entrants

      1. What services does your program provide persons entering your jurisdiction with TB classifications (e.g., B1, B2)

      2. If you like to add a hyperlink to an additional resource like your own health department page, please include the URL in the text box below.

         1. Add or modify a Spanish translation about services for migrants, if available.

   2. Costs and payment methods:

      1. Will newly entering persons with TB classifications (e.g., B1, B2, etc.) have costs associated with TB care in your jurisdiction? If yes, describe them here and explain methods of payment accepted.

      2. If you would like to add a hyperlink to an additional resource like your own health department page, please include the URL in the text box below.

         1. Add or modify a Spanish translation about services for migrants, if available.

   3. People experiencing TB symptoms:

      1. Who should newly entering persons with TB classifications (e.g. B1, B2, etc.) contact if they experience TB symptoms?

      2. If you like to add a hyperlink to an additional resource like your own health department page, please include the URL in the text box below.

         1. Add or modify a Spanish translation about services for migrants, if available.

   4. Linked locations: You have the option to include links to other relevant health departments’ guidance pages. For example, Gwinnett County, Georgia, may choose to include links to guidance uploaded by nearby Fulton and Dekalb counties. Please list other locations whose guidance you would like to include. Location names must be separated by commas and include state abbreviations when relevant: e.g., “Atlanta, GA, Dekalb, GA, Fulton County, GA.”

5. Jurisdiction assignment: You may set health departments’ jurisdictions as a state, region, county or city.

1. Are you requesting permissions to edit guidance for a state, region or county, city, tribal area? “Region” includes districts, counties, parishes (LA), municipalities (PR), and boroughs (AK). If you are using TB Care Finder as a regional health department, please see the job aid for further instructions.

2. Please enter the state or territory to which this TB guidance applies. Write names and not abbreviate. e.g., “California” or “New Mexico” or “Rhode Island.”

1. Publish your TB program to go live: The form does not allow you to save before publishing. Click the banner at the bottom left to SAVE AND CLOSE, so the public can view your description. If you click EXIT WITHOUT SAVING, TB Care Finder will show nothing new or retain information posted in an earlier session.

Public reporting burden of this collection of information is estimated to average 60 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 H21-8, Atlanta, Georgia 30333; ATTN: PRA 0920-1071