TB-400B_04_2020_CCHCS_Revised_03_2024v2.pdf

Status New Recurrent Reopen Prior Therapy Yes No stop date ATS Classification

0 - No M. TB Exposure, Not TB Infected 1 - M. TB Exposure, No Evidence of TB Infection 2 - M. TB Infection, No Disease 3 - M. TB Infection, Current Disease 4 - M. TB, No Current Disease 5 - M. TB Suspect, Diagnosis Pending

Predominant Site (Class 3, 4, 5):

Significant Sites (other than Predominant)

00 Pulmonary Bone and/or Joint 10 Pleural 40 Genitourinary 20 Lymphatic Miliary/Disseminated

21 Cervical Meningeal 22 Intrathoracic Peritoneal 23 Other Other (Specify)

Other Diagnosis Treatment for Active TB Disease Weight Height Regimen Start Restart

DOT:

DOT Site:

Frequency: 3x/week

Isoniazid mgs mgs mgs mgs mgs mgs mgs mgs mgs mgs mgs mgs

Rifampin Rifamate Pyrazinamide Ethambutol Streptomycin Ethionamide Capreomycin Amikacin Ciprofloxacin Ofloxacin Rifabutin

Prescribed for: months Maximum refills authorized:

Closure Date:

Doses taken by DOT:

Completion of adequate therapy Lost to followup Patient chose to stop Adverse drug reaction Deceased (Cause):

Moved out of state/country to:

Date referral sent to central office:

Pregnant Non-TB Other:

AFB Smear Results Current Negative Positive Pending Not done Specimen type: sputum urine bronchial washing biopsy other If biopsy or other, list anatomic site of specimen If other than sputa, type of exam Collection date of initial positive AFB smear Collection date of first consistently negative AFB smear Nucleic Acid Amplification Test

Current Negative Positive Indeterminate Not done

Culture Results Current

Positive for M.TB Negative

Non-M.TB, specify:

Specimen type: sputum urine bronchial washing biopsy other If biopsy or other, list anatomic site of specimen:

Collection date of initial positive MTB culture:

Collection date of first consistently negative MTB culture:

Sputum culture conversion documented? Yes No NA If no, specify reason:

Susceptibility Results Initial culture collected: Resistant to:

Reason Therapy Extending > 12 months:

YesHospitalization Advised: No Control Order:

Quarantine Advised: Yes No Compliant: Yes No

Nurse Signature Date

Physician Signature Date

Authorize nurse to obtain informed consent

Initial Report DR/MDR F/U or Medical Review

DOB

(First)

SSN

Apt# City

X (Check all that apply)D ta smotpmyS/sngiS Normal CT Scan

Normal Abnormal If Abnormal, check abnormality Status

Cavitary Non-cavitary, consistent with TB Worsening

Yes, country:

No Unknown

Non-cavitary, not consistent with TB Improving

Comments:

Unknown

TB-400B (4/2020)

CCHCS updated 03/2024

Report of Case and Patient Services

Date of earliest onset

If Pediatric TB Case (<15 Years Old) Country of birth for primary guardians:

Guardian 1:

Guardian 2:

Patient lived outside US for > 3 months

Abnormal

If yes, start date

Field VDOT

Isolation: Yes, date:

Court Action:

No, date released:

Provider decision:

Doses Taken:

Doses Recommended:

Months on Rx:

% Doses taken by DOT:

Months Recommended:

INH RIF EMB

Other resistance:

Last pos. culture collected: Resistant to: INH RIF Other resistance:

EMB

No Resistance

Pending Not done

Date reported to health department

NEDSS Hospital Admit/DC

Rifater Levofloxacin Moxifloxacin Rifapentine Bedaquiline Clofazimine Cycloserine Linezolid

PAS

B6 mgs mgs mgs mgs mgs mgs mgs mgs mgs mgs mgs mgs

Fever Weight Loss (≥ 10%) Chills Cough Productive Cough Hemoptysis Night Sweat

Public Health Clinic Private Physician Hospital Other (specify):

Stable

Name (Middle)

County Zip Code

Facility/Care Provider Name:

Facility responsible for patient care:

Name of person completing this form:

(Last)

Street

Date

Regimen Stop Stop

Yes No, specify reason:

Clinic or other medical facility

General Comments:

Other:

Daily:5x/week Daily: 7x/week 2x/week

CXR Date

EMRS/PIOS

Date form sent to PHR

Date form sent to central office e010068 Line e010068 Line