Tuberculosis Case Report Form
Use this form to report a tuberculosis case with key identification, clinical, exposure, and follow-up details.
Case Identification
Patient full name
*
First Name
Middle Name
Last Name
Date of birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Sex at birth / gender
*
Female
Male
Intersex
Prefer not to say
Prefer to self-describe
Current country/region or address location
*
Clinical and Diagnostic Details
Case status
*
Suspected
Confirmed
Not applicable
Date symptoms began
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Main symptoms present
Cough
Fever
Night sweats
Weight loss
Chest pain
Hemoptysis
Fatigue
Other
Test performed
Please Select
Sputum smear microscopy
Nucleic acid amplification test
Culture
Chest X-ray
Tuberculin skin test
Interferon-gamma release assay
Other
Test date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Exposure and History
Known exposure to a TB case?
*
Yes
No
Unknown
Household or close contact with a TB case?
*
Yes
No
Unknown
Travel or residence in a high-risk setting or area
Previous history of TB treatment or diagnosis
Please Select
No previous history
Previous diagnosis only
Previous treatment completed
Previous treatment incomplete
Unknown
Other
Treatment and Follow-up
Treatment started?
*
Yes
No
Treatment start date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Current medication regimen or treatment notes
Follow-up needed?
*
Yes
No
Reporting clinician or facility contact information
Submit
Should be Empty: