Form 1 Public Health Investigation Form: Active TB

OMB Control No: 0970-0509

Expiration date: 09/30/2026

Public Health Investigation Form: Active TB Unaccompanied Alien Children Bureau Office of Refugee Resettlement (ORR)

General Information

Child

Last name:

First name:

DOB:

A#:

Sex:

Program

Program name:

Person completing form & date:

Exposure Information

Source of potential exposure (e.g., staff member, other UC): ____________________________________________________________

Date of first potential exposure: ____ / ____ / ______

Date of last potential exposure: ____ / ____ / ______

Exposure details (e.g., child was potentially exposed for 4 hours a day in class for 5 consecutive days):

Was child screened for active TB signs/symptoms upon notification of exposure?

No

Yes, date: ____/____/______

If screened, did child have active TB signs/symptoms?

No

Yes

If Yes, was child evaluated by a healthcare provider?

No

Yes (Complete Medical Assessment Form)

Public Health Actions

Select No or Yes for each question below. If Yes, enter the information in the corresponding table.

PPD/Tuberculin skin test (TST):

No

Yes

Date Applied

Date Read

Reaction (mm)

Result

TB blood test (Interferon-Gamma Release Assay [IGRA]):

No

Yes

Test type (Quantiferon or T-Spot)

Collection Date

Result

Imaging study:

No

Yes

Imaging Study Type (e.g., 2-view)

Date Performed

Findings (Normal or Abnormal)

Medications given:

No

Yes

Medication name

Date started

Date discontinued

Dose

Directions

Psychotropic

No

Yes

No

Yes

Outcome of ORR public health investigation:

Pending Not screened; child has pre-existing LTBI

Cleared (negative TST/IGRA performed > 8 weeks post-exposure while in ORR custody)

Newly diagnosed LTBI (Complete Medical Assessment Form)

Diagnosed with active TB disease (Complete Medical Assessment Form)

Incomplete evaluation (discharged from ORR custody prior to > 8 weeks post-exposure TST/IGRA), reason (e.g., runaway, age-out): ___________________________________________________________________________

Comments:

The purpose of this information collection is to provide ORR with critical health information for unaccompanied children in the care of ORR. Public reporting burden for this collection of information is estimated to average 5 minutes per healthcare provider, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. This is a mandatory collection of information (6 U.S.C. §279: Exhibit 1, part A.2 of the Flores Settlement Agreement (Jenny Lisette Flores, et al., v. Janet Reno, Attorney General of the United States, et al., Case No. CV 85-4544-RJK [C.D. Cal. 1996]). An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information subject to the requirements of the Paperwork Reduction Act of 1995, unless it displays a currently valid OMB control number. The OMB # is 0970-0509 and the expiration date is 09/30/2026. If you have any comments on this collection of information, please contact [email protected].