TB-400A_03_21_2024v2.pdf

Other Change

SSN Medicaid # ID# DOB

Name (Last) (First) (Middle)

Street Apt# City County Zip Code Patient’s Tel.#

Facility/Care Provider Name________________________________________________________________________ ________________________________ Initial Reporting Source Health Dept Private Physician Public Hospital VA Hospital Name of person completing this form

Military Hospital TDCJ Other (Specify)

Notice of Arrival of Reported at Death Reported Out of State or Country Alien with TB Class Yes pecify ______________ No

Country of Birth

A B1 Yes No

Unknown SEX B2 B3 Was TB cause of death Hispanic or Latino Male

Yes No Unk Not Hispanic or Latino Female RACE (check all that apply) OCCUPATION (within past 2 years )

White Native Hawaiian Unemployed during last 2 yrs Unknown Othe or Pacific Islander Employed (If employed, check all that apply) Student Child

Black or American Indian Retiree Disabled African American or Alaskan Native

Migrant/Seasonal Worker Health Care Worker ( pecify) ________________________ Homemaker

Asian Unknown Correctional Emp Other Occupation Institutionalized

Resident of Correctional Facility at Time of Dx Yes No Unknown Incarceration Date If Yes Federal Prison State Prison County Jail City Jail Juvenile Correctional Facility ICE Other Resident of Long Term Care Facility at Time of Dx Yes No Unknown If Yes Nursing Home Hospital-Based Facility Residential Facility Mental Health Residential Facility

Alcohol/Drug Treatment Facility Other Long Term Care Facility Testing activities to find latent TB infection

Patient referred, TB infection Project targeted testing Individual targeted testing Administrative: Not at risk for TB

POPULATION RISKS MEDICAL RISKS

Low Income Diabetes mellitus Leukemia Chronic renal failure Inner-city resident Alcohol Abuse (within past year) Lymphoma Organ Transplant Foreign born Tobacco use _________________ Cancer of head Other ___________________

Silicosis Cancer of neck None of these medical Binational (US-Mexico) Within past 2 years Corticosteroids or other Drug abuse within past year: risks apply

Correctional employee* immunosuppressive therapy Injecting Health care worker* Gastrectomy or jejunoileal bypass Non-injecting Prison/Jail inmate* ge < 5 years Unknown if injecting

HIV TEST RESULTS

Long-term facility for Recent exposure to TB Positive Negative elderly/resident* (Contact to TB case) Pending Refused Health care facility/resident* Contact to MDR-TB case Not Offered Shelter for homeless persons* Weight at least 10% less than

HIV seropositive (only if laboratory confirmed) Tuberculin skin test conversion within 2 years

Migrant farm worker* ideal body weight Fibrotic lesions (on chest x-ray) Date CD4 Count None of the above risks apply Chronic malabsorption syndromes consistent with old, healed TB Results CD4 Count __ ____

TB SKIN TEST Yes No PRIOR LTBI TREATMENT

_______ mm Positive Negative Not Read Start Date

_______ mm Positive Negative Not Read Stop Date

FOR TREATMENT OF LTBI ONLY Date Normal Chest X-ray Weight ____________ Height _________ DOPT: Yes, totally observed No, self-administered Both ATS Classification DOPT Site: Clinic or medical facility Field Both 0 No M. TB Exposure, Not TB Infected Frequency: Daily Once Weekly Twice Weekly Three X’s Weekly 1 M. TB Exposure, No Evidence of TB Infection

2 M. TB Infection, No Disease R Start Stop 4 M. TB, No Current Disease

Restart Isoniazid ________ mgs Other (specify) _______________________ ________ mgs Rifampin ________ mgs B6 ________ mgs

Other (specify) _______________________ ________ mgs Prescribed for: ____ months Maximum refills autho ized: ______ Physician Signature Date

CLOSURE: Date Completion adequate therapy ______ # months on Rx ______ # months recommended Lost to followup Patient chose to stop Deceased (Cause) __________________________________________________ Adverse Drug Reaction Moved out of state/country to:__________________________________________

Provider decision: Pregnant Non-TB Other:_____________________________________________________________

Report of Case and Patient Services

Date reported to health department

TB-400A ( )

Initial Report Address Change

Preferred Language g

Date form sent to HSR

Date form sent to central o�ce

No

ETHNICITY

IGRA

t Other Change

SSN EMRS/PIOS # NEDSS # DOB

Name (Last) (First) (Middle)

Apt# City Zip Code Patient’s Tel.#

Health Dept Private Physician Military Hospital TDCJ

Notice of Arrival of Reported Out of State or Country Alien with TB Class Yes (specify): No

A B1 Unknown SEX B2 B3

Reported at Death

Hispanic or Latino Male Yes No Unk Not Hispanic or Latino Female

RACE (check all that apply) OCCUPATION (within past 2 years ) White UnknownEmployed (If employed, check all that apply)

Black or African American Asian

Health Care Worker (specify):

Migrant/Seasonal Worker Correctional Employee Other Occupation (specify):

Yes Unknown Incarceration Date If Yes Federal Prison State Prison County Jail City Jail Juvenile Correctional Facility ICE Other Resident of Long Term Care Facility at Time of Dx Unknown If Yes Nursing Home Residential Facility Mental Health Residential Facility

Alcohol/Drug Treatment Facility

Yes No Hospital-Based Facility Other Long Term Care Facility

POPULATION RISKS MEDICAL RISKS

Low Income Leukemia Inner-city resident Lymphoma Foreign born Cancer of head

Cancer of neck Binational (US-Mexico) Within past 2 years Drug abuse within past year:

End stage renal disease Organ Transplant Other:

None of these medical risks apply

Injecting Non-injecting Unknown if injecting

HIV TEST RESULTS

Positive Negative Refused

Correctional employee* Health care worker* Prison/Jail inmate* Long-term care facility* Health care facility/resident* Homeless in past 12 months Homeless ever Migrant farm worker* None of the above risks apply

Diabetes mellitus Alcohol Abuse (within past year) Tobacco use:

Silicosis Immunosuppressive therapy TNF-α antagonist therapy Gastrectomy or jejunoileal bypass ge < 5 years Recent exposure to TB (Contact to TB case) Contact to MDR-TB case Weight at least 10% less than ideal body weight Chronic malabsorption syndromes

HIV seropositive (only if laboratory confirmed) TST/IGRA conversion within 2 years Fibrotic lesions (on chest x-ray) consistent with old, healed TB

Pending Not Offered

Date CD4 Count Results CD4 Count

TB Skin Test IGRA PRIOR LTBI TREATMENT mm Positive Negative Start Date

Positive Negative

Yes No

Not read/indeterminate/borderline

Not read/indeterminate/borderline Stop Date

FOR TREATMENT OF LTBI ONLY Date Normal Chest X-ray:

Yes, totally observed Clinic or medical facility Daily Once Weekly

No, self-administered Field VDOT

DOPT:

DOPT Site:

Frequency: Twice Weekly

0 No M. TB Exposure, Not TB Infected 2 M. TB Infection, No Disease 1 M. TB Exposure, No Evidence of TB Infection 4 M. TB, No Current Disease

Physician Signature Date

CLOSURE: Date

Lost to follow-up Patient chose to stop # months on Rx # months recommended

Adverse drug reaction Provider decision: Pregnant Non-TB

Completion adequate therapy Deceased (Cause):

Moved out of state/country to:

Other:

Report of Case and Patient Services

TB-400A (4/2020)

CCHCS updated 03/2024

Initial Report Address Change

Country of Birth Date of U.S. Entry (if foreign born) Eligible for U.S. Citizenship/ Nationality at Birth?

Preferred Language

Date reported to health department Date form sent to

PHR

Date form sent to central office

No

ETHNICITY

Isoniazid mgs Rifampin mgs Rifapentine mgs

B6 mgs Other (specify): mgs

Prescribed for: months Maximum refills authorized:

Regimen Start Date Stop Date

Stop Date

(Alias) mm

Regimen Restart Date

Was TB cause of death?

Yes No

Hospital Admission

Street Facility/Care Provider Name

Initial Reporting Source

County Name of person completing this form Public Hospital VA Hospital Other (Specify)

Weight

Height

American Indian or Alaskan Native Unknown

Native Hawaiian or Pacific Islander

Resident of Correctional Facility at Time of Dx

Unemployed during last 2 yrs

Documented hx of positive TST or IGRA?

ATS Classification

General Comments:

Initial Reason Evaluated for TB Contact Investigation

Immigration Med. Exam

Abnormal

CXRHCW

Employment Testing

No

Target Testing

TB

Symptoms Incident Lab Result

Test Type