TB-340_Report_of_Follow_Up_Treatment_for_Contacts_10_12_2011_FILLABLEv2.pdf
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- Attached to
- Electronic Health Records
- Solicitation number
- 2024-280
- Issued by
- Collin County, Texas
About this file
The document is a Texas Health and Human Services TB Program Evaluation Report for Follow-up and Treatment for Contacts to TB Cases and Suspects, specifically form TB-340 dated 10/12/2011. This standardized form is designed to comprehensively document tuberculosis case information, patient details, exposure sites, interview data, and contact tracing. The form captures critical epidemiological information including patient demographics, case status, predominant disease sites, bacteriology results, treatment adherence, and potential exposure locations such as homes, daycares, nursing homes, hospitals, correctional facilities, and public transportation.
The form includes extensive sections for medical and social risk assessment, with checkboxes for various priority criteria like age groups, facility types, and social behavioral risks. It allows healthcare professionals to track testing dates (TST, IGRA), specimen collection, smear and culture results, chest x-ray readings, and treatment start dates. Additional details include patient marital status, ethnicity, contact information, interview dates, and options to note reasons for limited contact identification such as patient refusal, patient death, or lack of contact information. The form is designed to support comprehensive tuberculosis case management and public health tracking.
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Text version
TB Program Evaluation Report of Follow-up and Treatment for Contacts to
TB Cases and SuspectsA. Case/Suspect Information Last Name First Name Middle Name DOB SSN Sex Race Ethnicity
Date
Street Address Apt. City County Zip Code Census Tract Home Phone Work Phone
Status:
New RecurrentSuspect Reopen
Predominant Sites: Is Case Married?
Yes No
Daycare Attendee/Employee?
Yes No
M F
Pulmonary Laryngeal Other
White Black/Afr. American Asian Amer. Indian/Alaskan
Hawaiian/Pacific Is.Other
Hispanic/Latino
Not Hispanic/Latino
Dates of Infectious Period
Page 1 of
TST Date mm Positive Yes No
Bacteriology Specimen Collection Date Smear Culture Resistant to:Culture ID
Date Treatment Started:
CXR Date Reading Cavitary
Yes No
Adherent to Treatment?
Source Case:
Yes No
Name: Last, First, Middle
Fewer than 3 contacts identified due to:
Comments:
B. Interview & Exposure Site Information Interview Date Interviewed by: Last Name First Name: Date Home/Other Site Visit 3:Clinic:
TB-340 (10/12/2011)
Patient refused to cooperate Patient lost to follow-up
Patient died No contact information available
Other (Specify)
Did patient have contact with livestock or consume unpasteurized dairy?
NoYes
Identified in prior contact investigation?
Yes No
Priority Criteria Pos Sputum Smear Pos Sputum Culture Cavitary X-Ray Pulmonary
Laryngeal Miliary
MDR-TB
Child (<5)
Child (5-<15) Correctional Facility Inmate Long term Facility Resident Recent Convertor
Site Name Location Site Type
Home/Residence
Est. # Exposed Daycare
School/College Office/Workplace
Nursing Home
Hospital/Medical
Correctional Facility
Airplane/Pub. Transport.
Leisure/Recreation
Other (Specify):
Media Involvement? Yes No If yes, media source and contact
Colonia Dorm
Case:
Unknown
DOT
IGRA Date Positive Yes No
Yes No
Date assistance requested: Name of assistant:
Social Behavioral Risk 900 Positive HBV Positive Excessive alcohol use Other substance use
Interview Date (>7 days after)
Site #
To
Home/Residence
Daycare School/College Office/Workplace
Nursing Home
Hospital/Medical
Correctional Facility
Airplane/Pub. Transport.
Leisure/Recreation
Other (Specify):
Colonia Dorm
Home/Residence
Daycare School/College Office/Workplace
Nursing Home
Hospital/Medical
Correctional Facility
Airplane/Pub. Transport.
Leisure/Recreation
Other (Specify):
Colonia Dorm
Home/Residence
Daycare School/College Office/Workplace
Nursing Home
Hospital/Medical
Correctional Facility
Airplane/Pub. Transport.
Leisure/Recreation
Other (Specify):
Colonia Dorm
RVCT #:
Mental Illness Dementia
Date Home/Other Site Visit 1:
Date Home/Other Site Visit 2: Date Home/Other Site Visit 4:
| Page-1� |
| Page-2� |
| Number of Pages: |
| Date of Report mm: |
| Date of Report dd: |
| Date of Report yyyy: |
| RVCT1: |
| RVCT2: |
| RVCT3: |
| Case Suspect Name: |
| Case DOB mm: |
| Case DOB dd: |
| Case DOB yyyy: |
| SSN1: |
| SSN2: |
| SSN3: |
| Case Gender: Off |
| White: Off |
| BlackAfr American: Off |
| Asian: Off |
| Amer IndianAlaskan: Off |
| Other: Off |
| HawaiianPacific Is: Off |
| HispanicLatino: Off |
| Not HispanicLatino: Off |
| Street Address Apt City County Zip Code Census Tract: |
| Hm Phone1: |
| Hm Phone2: |
| Hm Phone3: |
| Wk Ph1: |
| Wk Ph2: |
| Wk Ph3: |
| Suspect: Off |
| New: Off |
| Recurrent: Off |
| Reopen: Off |
| Pulmonary: Off |
| Laryngeal: Off |
| Other Site: Off |
| Other Predominant Sites: |
| Is Case Married: Off |
| Daycare AttendeeEmployee: Off |
| TST Date mm: |
| TST Date dd: |
| TST Date yyyy: |
| mm: |
| Tx Started mm: |
| Tx Started dd: |
| Tx Started yyyy: |
| IGRA mm: |
| IGRA dd: |
| IGRA yyyy: |
| CXR Date mm: |
| CXR Date dd: |
| CXR Date yyyy: |
| Reading: |
| Start Infectious mm: |
| Start Infectious dd: |
| Start Infectious yyyy: |
| End Infectious mm: |
| End Infectious dd: |
| End Infectious yyyy: |
| Source Name: |
| Unknown Source: Off |
| Patient refused to cooperate: Off |
| Patient died: Off |
| Patient lost to followup: Off |
| No contact information available: Off |
| Other Specify: Off |
| Other Fewer than 3 Contacts: |
| Date assistance mm: |
| Date assistance dd: |
| Date assistance yyyy: |
| Assistant: |
| Specimen1: |
| Positive TST: Off |
| Collection1: |
| Smear1: |
| Culture1: |
| CultureID1: |
| Specimen2: |
| Collection2: |
| Smear2: |
| Culture2: |
| CultureID2: |
| Specimen3: |
| Cavitary: Off |
| Adherent to Treatment: Off |
| Collection3: |
| Smear3: |
| Culture3: |
| CultureID3: |
| Comments: |
| unpasteurized dairy: Off |
| investigation: Off |
| Pos Sputum Smear: Off |
| Pos Sputum Culture: Off |
| Cavitary XRay: Off |
| Pulmonary_2: Off |
| Laryngeal_2: Off |
| Miliary: Off |
| MDRTB: Off |
| Child 5: Off |
| Child 515: Off |
| Correctional Facility Inmate: Off |
| Long term Facility Resident: Off |
| Recent Convertor: Off |
| 900 Positive: Off |
| HBV Positive: Off |
| Excessive alcohol use: Off |
| Other substance use: Off |
| Mental Illness: Off |
| Dementia: Off |
| 1st Interview mm: |
| 1st Interview dd: |
| 1st Interview yyyy: |
| 1st Interview Last Name: |
| 1st Interview First Name: |
| 2nd interview mm: |
| 2nd interview dd: |
| 2nd interview yyyy: |
| 2nd interview Last Name: |
| 2nd interview First Name: |
| Clinic1: |
| Clinic2: |
| Home Other VIsit 1 mm: |
| Home Other Visit 1 dd: |
| Home Other Visit 1 yyyy: |
| Home Other Visit 2 mm: |
| Home Other Visit 2 dd: |
| Home Other Visit 2 yyyy: |
| Home Other Visit 3 mm: |
| Home Other Visit 3 dd: |
| Home Other Visit 3 yyyy: |
| Home Other Visit 4 mm: |
| Home Other Visit 4 dd: |
| Home Other Visit 4 yyyy: |
| Site Name1: |
| Location1: |
| AirplanePub Transport: Off |
| Colonia: Off |
| Correctional Facility: Off |
| Daycare: Off |
| Dorm: Off |
| HomeResidence: Off |
| HospitalMedical: Off |
| LeisureRecreation: Off |
| Nursing Home: Off |
| OfficeWorkplace: Off |
| SchoolCollege: Off |
| Other Site1: Off |
| Est ExposedHomeResidence Daycare SchoolCollege OfficeWorkplace Nursing Home HospitalMedical Correctional Facility AirplanePub Transport LeisureRecreation Other Specify Colonia Dorm: |
| Site Name2: |
| Location2: |
| AirplanePub Transport_2: Off |
| Colonia_2: Off |
| Correctional Facility_2: Off |
| Daycare_2: Off |
| Dorm_2: Off |
| HomeResidence_2: Off |
| HospitalMedical_2: Off |
| LeisureRecreation_2: Off |
| Nursing Home_2: Off |
| OfficeWorkplace_2: Off |
| SchoolCollege_2: Off |
| Other Site2: Off |
| Est ExposedHomeResidence Daycare SchoolCollege OfficeWorkplace Nursing Home HospitalMedical Correctional Facility AirplanePub Transport LeisureRecreation Other Specify Colonia Dorm_2: |
| Site Name3: |
| Location3: |
| AirplanePub Transport_3: Off |
| Colonia_3: Off |
| Correctional Facility_3: Off |
| Daycare_3: Off |
| Dorm_3: Off |
| HomeResidence_3: Off |
| HospitalMedical_3: Off |
| LeisureRecreation_3: Off |
| Nursing Home_3: Off |
| OfficeWorkplace_3: Off |
| SchoolCollege_3: Off |
| Other Site3: Off |
| Est ExposedHomeResidence Daycare SchoolCollege OfficeWorkplace Nursing Home HospitalMedical Correctional Facility AirplanePub Transport LeisureRecreation Other Specify Colonia Dorm_3: |
| Site Name4: |
| Location4: |
| AirplanePub Transport_4: Off |
| Colonia_4: Off |
| Correctional Facility_4: Off |
| Daycare_4: Off |
| Dorm_4: Off |
| HomeResidence_4: Off |
| HospitalMedical_4: Off |
| LeisureRecreation_4: Off |
| Nursing Home_4: Off |
| OfficeWorkplace_4: Off |
| SchoolCollege_4: Off |
| Other Site4: Off |
| Est ExposedHomeResidence Daycare SchoolCollege OfficeWorkplace Nursing Home HospitalMedical Correctional Facility AirplanePub Transport LeisureRecreation Other Specify Colonia Dorm_4: |
| Positive IGRA: Off |
| DOT: Off |
| Media Source and Contact: |
| Media Involvement: Off |
| Resistance2: [--] |
| Resistance1: [--] |
| Resistance3: [--] |
| Case Notes: |
File details come from the government source that posted it. Updated .