Tuberculosis Contact Investigation Report

Tuberculosis Contact Investigation Report for TB Suspect/Case for Corrections Suspect/Case Information

REPORTING FACILITY / NAME
ADDRESS
PERSON COMPLETING FORM / EMAIL
PHONE / CELL / FAX
INMATE DEMOGRAPHICS / CONTACT INVESTIGATION START DATE
SUSPECT/CASE NAME
(INCLUDE ALIASES) / DOB / RACE/SEX / COUNTRY OF ORIGIN
INMATE’S HOME ADDRESS
HOME/CELL PHONE # / CONTACT/RELATIVE NAME / CONTACT PHONE #
HOUSING / INMATE’S CURRENT LOCATION:
LIST HOUSING UNITS
(during infectious period) / Open Dorm / Open Dorm / Single Cell / Single Cell / Direct Supervision Cell / Other Housing
Location/Name:
NUMBER INMATES POTENTIALLY EXPOSED
NUMBER STAFF POTENTIALLY EXPOSED
TRANSPORTATION
Transportation type: # of transports during infectious period: / Length of time in vehicle with others:
Other potential exposure locations (specify):
INDEX CASE (INMATE) MEDICAL INFORMATION / BACTERIOLOGY
SITE OF DISEASE / Pulmonary / SPECIMEN:
(if more than one positive, note under “other”, e.g. #1 of 3) / Sputum Other
Other / SMEAR / DATE
SYMPTOMS / DATE ONSET / Positive / Negative / Pending / Not Done
Cough Yes No / Producing Sputum Yes No / NAA (MTD) / DATE
Fever Yes No / Weight Loss Yes No / Positive / Negative / Pending / Not Done
Night Sweats Yes No / Other / CULTURE / DATE
CHEST X-RAY / DATE / M.tb. / Negative / Pending / Not Done
Normal / Cavitary / SENSITIVITIES RETURNED / Pansensitive / Resistant
Other: / Non-Cavitary / RESISTANT TO:
ASSESSMENT OF RISK FOR TRANSMISSION / Higher risk to transmit TB Lower risk to transmit TB
DATE OF INFECTIOUSNESS: FROM TO / INTERVIEW DATE
INTERVIEWER / POSITION
PHONE / CELL
HEALTH DEPARTMENT CONTACT INVESTIGATOR
CORRECTIONS CONTACT INVESTIGATOR

southeastern national tuberculosis center (sntc) u http://sntc.medicine.ufl.edu u 888-265-7682 u

Contacts to Suspect/Case - Information

CONTACT INFORMATION
Copy this form for additional contacts / DOB OR AGE / LOCATION / DURATION / PRIORITY FOR FOLLOW-UP / RESIDENCE / DATE OF LAST EXPOSURE / TST / CHEST
X-RAY / TREATMENT FOR LATENT TB INFECTION (LTBI) INITIATED?
LAST, FIRST
SSN (IF KNOWN) / HOUSING
OR CELL / WORK / SHORT DURATION / LONG DURATION / HIGH / MEDIUM / ADDRESS / CITY / STATE / ZIP / INITIAL TST / RETEST / INDICATE THE FOLLOWING REASONS:
Contact (1), Recent Converter (2), Negative (3) Not Started due to Medical Advice (4), Refused (5), Lost (6), Other – specify (7)
Date / Date / Date / Started Meds: Yes No Date
Meds: INH RIF Other
Reason 1 2 3 4 5 6 7
Reading / Reading / Normal / Other (7), Specify:
SSN / Phone / mm / mm / Abnormal / DOT? Yes No Completed Tx? Yes No Date
Date / Date / Date / Started Meds/Not Started: Yes No Date
Meds: INH RIF Other
Reason 1 2 3 4 5 6 7
Reading / Reading / Normal / Other (7), Specify:
SSN / Phone / mm / mm / Abnormal / DOT? Yes No Completed Tx? Yes No Date
Date / Date / Date / Started Meds/Not Started: Yes No Date
Meds: INH RIF Other
Reason 1 2 3 4 5 6 7
Reading / Reading / Normal / Other (7), Specify:
SSN / Phone / mm / mm / Abnormal / DOT? Yes No Completed Tx? Yes No Date
Date / Date / Date / Started Meds/Not Started: Yes No Date
Meds: INH RIF Other
Reason 1 2 3 4 5 6 7
Reading / Reading / Normal / Other (7), Specify:
SSN / Phone / mm / mm / Abnormal / DOT? Yes No Completed Tx? Yes No Date
Date / Date / Date / Started Meds/Not Started: Yes No Date
Meds: INH RIF Other
Reason 1 2 3 4 5 6 7
Reading / Reading / Normal / Other (7), Specify:
SSN / Phone / mm / mm / Abnormal / DOT? Yes No Completed Tx? Yes No Date
Date / Date / Date / Started Meds/Not Started: Yes No Date
Meds: INH RIF Other
Reason 1 2 3 4 5 6 7
Reading / Reading / Normal / Other (7), Specify:
SSN / Phone / mm / mm / Abnormal / DOT? Yes No Completed Tx? Yes No Date
Date: / Date: / Date: / Started Meds/Not Started: Yes No Date
Meds: INH RIF Other
Reason 1 2 3 4 5 6 7
Reading / Reading / Normal / Other (7), Specify:
SSN / Phone / mm / mm / Abnormal / DOT? Yes No Completed Tx? Yes No Date

southeastern national tuberculosis center (sntc) u http://sntc.medicine.ufl.edu u 888-265-7682 u