Document
TB Maritime Investigation Worksheet
ICR 202603-0920-015 · OMB 0920-1335 · Object 167649600.
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Document Metadata
| File Type | application/vnd.openxmlformats-officedocument.spreadsheetml.sheet |
|---|---|
| File Title | TB Maritime Investigation Worksheet |
| Conversion State | complete |
Extracted Text
Demographic Information Contact Number 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Initials Age Country of Birth Epidemiologic History Country of Residence Date of last Contact Type exposure to case (Crew/Passenger) Does contact have a previous history of a TB diagnosis? (Y/N) Contact M High-risk contact*? (Y/N) If contact is no longer on the vessel, was the Is contact still on vessel company (if Was contact the vessel? (Y/N) crew) or CDC (if interviewed? (Y/N) passenger) notified? (Y/N) Contact Management Does this person have any signs or symptoms of TB^? (Y/N) If a high-risk contact* without TB If a chest X-ray was signs/symptoms, done, did it show any how was contact signs of TB? (Y/N) assessed for latent TB (LTBI)¥? Results of high-risk contact LTBI screening Crew Passenger Y N TST Positive IGRA Negative Not Done Indeterminate