Tuberculosis Surveillance and Case Management Report
Name
First Name
Middle Initial
Last Name
Date of Birth
Gender
Male
Female
Race
American Indian/Alaska Native
Asian
African-American/Black
Native Hawaiian/Pacific Islander
White
Unknown
Ethnicity
Not Hispanic/Latino
Hispanic/Latino
Country of Birth
United States
Mexico
Other
Date Arrived in the U.S.
Month/Year
Date Arrived in Colorado
Month/Year
Country of Birth of Parents/Guardians
Under 18 years old
Occupation
Healthcare worker
Corrections employee
Migrant/seasonal worker
Unemployed past 12 months
Not seeking employment
Retired
Unknown
Other
Employer
Current Home Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Other Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Work Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Other Phone
Please enter a valid phone number.
Format: (000) 000-0000.
If other, what type of phone number is this?
Email
example@example.com
Preferred Language
Interpreter Needed?
Yes
No
Insurance
Medicaid, Medicare, private (name), none
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Reason for evaluation
Administrative
Class B TB notification
Incidental lab result
Employment
Immigration medical exam
Abnormal CXR
Known active
Healthcare worker
Suspect case
Symptomatic
Targeted testing-individual
Targeted testing-pregnancy
Targeted-testing specific project
Transfer case/suspect
Contact investigation
Source case investigation
If due to contact investigation or source case investigation, index case TBdb#
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TST and IGRA
Current TST
Date placed
Date read
Induration
mm
Previous TST
Date
Induration
mm
TST Conversion in Last 2 Years
Yes
No
IGRAs
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Collection Date
Testing Laboratory
Type of IGRA
Quantiferon (Qiagen)
T-Spot
Other
IGRA Results
Positive
Negative
Indeterminate
Unknown
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Imaging
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Imaging
X-Ray
CT
MRI
Date taken
Name of facility
Previous imaging
Yes
No
Unknown
Name of facility
Date taken
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Medical History
Symptoms
Rows
Symptoms
Symptom Length
None
1
Cough
2
Hemoptysis
3
Chest pain
4
Weight loss
5
Night sweats
6
Urinary
7
Fever
8
Other (please specify)
9
Medical History
Rows
Not Satisfied
Notes
None
10
Gastrectomy
11
Jejunoileal bypass
12
GU problems
13
Weight loss > 10lbs
14
GI issues
15
Diabetes mellitus
16
Renal failure
17
HIV
18
Immunosuppressive therapy
19
Chest injury
20
Heart disease
21
Silicosis
22
Lung disease
23
Hepatitis
24
Liver disease
25
Transfusion
26
Surgeries
27
Cancer
28
Other
29
Special Conditions
Rows
Not Satisfied
Expected Delivery Date
Pregnant
30
Postpartum breastfeeding
31
Weight
Height
Previous TB Diagnosis?
TB Infection
TB disease
Completed treatment for TBI or TBD-Documented
Completed treatment for TBI or TBD-Verbal
No
Unknown
BCG Vaccine
Yes
No
If yes, date of vaccine.
Drug allergies:
Medications
Rows
Name
Dose
Purpose
Start Date
Medication 1
Medication 2
Medication 3
Medication 4
Medication 5
Medication 6
Smoker?
Yes
No
If yes, what type?
Current
Past
Date quit, if applicable
Packs per day
Exposure risks
None
Homelessness
Refugee camp
Patient lived/traveled outside of US for >1 month
Exposure risks
Rows
Not Satisfied
Please Describe
None
32
Homeless
33
Refugee camp
34
Patient lived/traveled outside of US f >1 month
35
Resident of long term care facility
36
HIV Test
Positive
Negative
Not done
Unknown
HIV Test Date, if applicable
Alcohol Use
Yes
No
Unknown
Drinks per week
Drug use
Injecting
Non-injecting
No
Unknown
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PCP/Clinic Name
PCP Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
PCP/Clinic Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
PCP Fax Number
Please enter a valid phone number.
Format: (000) 000-0000.
Name of Person Completing this Form
First Name
Last Name
Additional Comments or Notes
Submit
Should be Empty: