TB-341_Continued_Report_of_Follow_Up_Treatment_for_Contacts_10_12_11_FILLABLE_7_23_13v2.pdf

Last Name First Middle

Address

City County or Country

Phone #:

SSN

Gender Male Female

Race Hispanic/Latino Not Hispanic/Latino

DOB

BCG Yes No

Relation to case:

TST/IGRA Date mm/%

CXR Date Normal Abnormal

Treatment Started: Treatment Stopped: # Months Recommended:

# Months RX Completed: Clinic:

Exposure Length >6 hrs/wk >2 but <6 hrs/wk <2 hrs/wk

C. Contact Information

Case/Suspect Information Last Name First Name Middle Name DOB SSN

Date

Page of

Date:

Pos Neg

PA Lateral Lordotic

Evaluation Complete? Yes No If No, Reason Not Complete:

Died Lost to Follow-up Refused Evaluation 1st TST not done/read

2nd TST not done/read 3rd TST not done/read

No Chest X-Ray

Treatment Recommended? Yes No Reason Treatment not started:

Contraindicated Died History of noncompliance Lost to follow-up Prior adequate treatment Refused treatment

History of positive TST? Yes No

900 Test Results Pos Neg Unk

Date

Ongoing exposure? Yes No If no, date last exposure

No contact was made

Country of Birth (if not US):

Completed adequate therapy Treatment Outcome (if recommended)

Lost/patient not located Refused (patient chose to stop meds Refused (patient chose to stop evaluation) Adverse treatment event Died Moved out of state/country Provider decision-pregnant Provider decision-other (specify):

No further evaluation needed Active TB developed

TB-341 (10/12/2011)

TB Program Evaluation Report of Follow-up and Treatment for Contacts to

TB Cases and Suspects

Date Identified:

Home Work

Exposure Setting Indoors:

Size of bedroom Size of house Larger than house

Outdoors Other

Site #

Priority (H, M, L):

ATS Class

Size of car 0

Last Name First Middle

Address

City County or Country

Phone #:

SSN

Gender Male Female

Race Hispanic/Latino Not Hispanic/Latino

DOB

BCG Yes No

Relation to case:

TST/IGRA Date mm/%

CXR Date Normal Abnormal

Treatment Started: Treatment Stopped: # Months Recommended:

# Months RX Completed: Clinic:

Exposure Length >6 hrs/wk >2 but <6 hrs/wk <2 hrs/wk

Date:

Pos Neg

PA Lateral Lordotic

Evaluation Complete? Yes No If No, Reason Not Complete:

Died Lost to Follow-up Refused Evaluation 1st TST not done/read

2nd TST not done/read 3rd TST not done/read

No Chest X-Ray

Treatment Recommended? Yes No Reason Treatment not started:

Contraindicated Died History of noncompliance Lost to follow-up Prior adequate treatment Refused treatment

History of positive TST? Yes No

900 Test Results Pos Neg Unk

Date

Ongoing exposure? Yes No If no, date last exposure

No contact was made

Country of Birth (if not US):

Completed adequate therapy Treatment Outcome (if recommended)

Lost/patient not located Refused (patient chose to stop meds Refused (patient chose to stop evaluation) Adverse treatment event Died Moved out of state/country Provider decision-pregnant Provider decision-other (specify):

No further evaluation needed Active TB developed

Date Identified:

Home Work

Exposure Setting Indoors:

Size of bedroom Size of house Larger than house

Outdoors Other

Site #

Priority (H, M, L):

ATS Class

Size of car 0

Last Name First Middle

Address

City County or Country

Phone #:

SSN

Gender Male Female

Race Hispanic/Latino Not Hispanic/Latino

DOB

BCG Yes No

Relation to case:

TST/IGRA Date mm/%

CXR Date Normal Abnormal

Treatment Started: Treatment Stopped: # Months Recommended:

# Months RX Completed: Clinic:

Exposure Length >6 hrs/wk >2 but <6 hrs/wk <2 hrs/wk

Date:

Pos Neg

PA Lateral Lordotic

Evaluation Complete? Yes No If No, Reason Not Complete:

Died Lost to Follow-up Refused Evaluation 1st TST not done/read

2nd TST not done/read 3rd TST not done/read

No Chest X-Ray

Treatment Recommended? Yes No Reason Treatment not started:

Contraindicated Died History of noncompliance Lost to follow-up Prior adequate treatment Refused treatment

History of positive TST? Yes No

900 Test Results Pos Neg Unk

Date

Ongoing exposure? Yes No If no, date last exposure

No contact was made

Country of Birth (if not US):

Completed adequate therapy Treatment Outcome (if recommended)

Lost/patient not located Refused (patient chose to stop meds Refused (patient chose to stop evaluation) Adverse treatment event Died Moved out of state/country Provider decision-pregnant Provider decision-other (specify):

No further evaluation needed Active TB developed

Date Identified:

Home Work

Exposure Setting Indoors:

Size of bedroom Size of house Larger than house

Outdoors Other

Site #

Priority (H, M, L):

ATS Class

Size of car 0