Free Interjurisdictional Tuberculosis Notification, DPH 42010 - Wisconsin

DEPARTMENT OF HEALTH AND HUMAN SERVICES Division of Public Health DPH 42010 (03/03)

STATE OF WISCONSIN s. 252.10 (7), Wis. Stats. (608) 266-9692 FAX: (608) 266-0049

INTERJURISDICTIONAL TUBERCULOSIS NOTIFICATION
Client Information is confidential under Wisconsin Statue 146.82 (1)

REFERRING JURISDICTION
City Contact Person ­ Name County State Telephone Number (Include area code) Date Sent Fax Number (Include area code)

REFERRAL CATEGORY
Verified case. State reporting to CDC Suspect case Close contact Reactor (LTBI) RVCT Number (attach RVCT) Convertor (LTBI) Not reported A/B Classified Immigrant Source case investigation

PATIENT INFORMATION
Patient Name (Last, First, Middle Initial) Patient is also known as (Alias, Nickname, etc.) New Telephone Number ( ) ) Gender M Date of Birth F

New Address (Street, Apartment Number, City, State and Zip Code) Name - Emergency Contact and Telephone Number (

Date of Expected Arrival

Relationship to Patient

Name - New Health Provider (If known provide Name, Address and Telephone Number) Interpreter needed? Yes If yes, specify language No Hispanic Yes No Race White Alaskan Native Black Other Asian American Indian

CLINICAL INFORMATION
Date of Collection

This referred Case/Suspect
Smear

Index Case For This Contact
Culture Susceptibility

Not Applicable
Chest X-ray Other

Specimen Type

Site(s) of Disease Other(s) specify Date TST No. 1

Pulmonary

Date 1 st Negative Smear

Not yet

Date 1 st Negative Culture

Not yet

Result

mm

Date TST No. 2

Result

mm

CONTACT/LTBI INFORMATION TB SkinTest
Date CXR

Not Done
Not Done Other

Date TST No. 1 Normal

Result

mm

Date TST No. 2 Place/intensity of exposure

Result

mm

Date of last known exposure to index case

MEDICATIONS
Drug

This referred case/suspect
Dose Start Date

This referred contact/LTBI
Stop Date Planned Completion Date: DOT Yes Daily No 1xW Date: days of medication. Start Date: 2xW 3xW

Last DOT Patient given

Adherence problems/significant drug side effects: Comments

NOTE:

Follow-Up Requested

No Follow-Up Requested

Adapted with permission from the National Tuberculosis Controllers Association (NTCA 3-2002)

DPH 42010I (03/03)

INSTRUCTIONS FOR INTERJURISDICTIONAL TB NOTIFICATION
This form is to be completed by the health care worker responsible for transferring information on tuberculosis (TB) patients. The completed form can be faxed or mailed to the health department responsible for serving the patient at the new address. This form facilitates interstate as well as intrastate communication to enhance continuity and completeness of care for patients on medications for tuberculosis infection or disease. It should also improve outcome evaluation of verified cases, case contacts and other persons on treatment for latent TB infection. TB notifications will be exchanged between state health departments and/or the appropriate local health departments in the receiving jurisdiction. Client information on this form is confidential under Wis. Stat. 145.82 (1). For TB disease cases and suspect cases, an Interjurisdictional TB Notification should always be initiated when a patient will be moving out of the area for 30 days or more. Notification may be initiated for patients with shorter planned stays or if less than 30 days of treatment remain to be completed at the time of their move, at the discretion of the referring jurisdiction. For example, if a patient must continue directly observed therapy (DOT) after they move, a notification should be initiated. NOTE: Obtain the new street address or telephone number from patient prior to sending this form. Do not send this form unless reasonable location information is available, usually consisting of at least a street address or phone number. DEFINITIONS Interjurisdictional TB Notification: Provides a standard array of information to be transmitted to new jurisdictions for TB disease cases, contacts and persons with latent TB infection (LTBI) and source case findings. Referring jurisdiction: The jurisdiction that initiates the interjurisdictional notification. Receiving jurisdiction: The jurisdiction that receives the interjurisdictional notification. Referral Category: The category that defines the condition of the patient being referred. Verified Case: An individual has confirmed, clinically active TB disease and the episode is being counted as a case in original jurisdiction. RVCT: The Report of Verified Case of TB is the national form used to report verified cases to the Centers for Disease Control and Prevention (CDC). Suspect Case: An individual with illness marked by symptoms such as prolonged cough, prolonged fever, hemoptysis; compatible radiographic or medical imaging findings; or laboratory tests that may be indicative of tuberculosis. Close Contacts: An individual with close prolonged contact to AFB smear positive or smear negative pulmonary cases. If there are multiple contacts to the same case, they should have individual notifications sent. LTBI Convertors: A person who has had an increase of 10 mm or more of induration in the tuberculin skin test (TST) results within a two year period. The results and dates of the last negative skin test and the first positive skin test must be entered into the Contact/LTBI section to provide information on when skin test conversion occurred. (Note: For this form, convertors who are close contacts should be identified as contacts and not convertors.) LTBI Reactors: Patients with LTBI that are not documented convertors or are not part of a contact investigation. Include specific risk factors for disease progression to assist receiving jurisdictions to prioritize follow-up. Source Case Investigation: Investigation of close associates to a index case when the index case has a clinical presentation consistent with recently acquired disease (e.g. children 3 years of age). Notification should not routinely be sent to perform source case finding for a child with LTBI only. A/B Classified Immigrant: Immigrant (includes individuals identified as refugees, or on K1 fiancé and K2 visas) with a class A or B TB related condition that was identified during medical evaluation prior to the client's departure from their originating country. F/U 2: The Follow-Up 2 (F/U 2) is the national form used to report outcomes of verified cases to the CDC. INSTRUCTIONS Referring Jurisdiction Information: Complete all information for the receiving jurisdiction. Referral Category: Specify type of patient referral. For verified cases, supply the RVCT number and state that reported to CDC. This will allow the receiving jurisdiction to ensure the F/U 2 is sent to the reporting jurisdiction. Attach the RVCT form whenever possible. For classified immigrant, attach pertinent overseas forms when available. Patient Information: Complete all information. If some elements are unknown, indicate this in the space provided. The Emergency Contact should be a relative or associate who is likely to have locating information about the referred patient. Clinical information: When some or all of the laboratory information is pending at the time of referral, the referring jurisdiction should indicate this and update the information when available. Attach copies of laboratory and x-ray information whenever possible. Contact/LTBI information: This section should be used for contacts, convertors, and reactors. The TB skin test #1 and #2 should be complete for all convertor referrals and for other referrals when appropriate. For contact referrals, exposure information should be completed to enhance appropriate investigation by the receiving jurisdiction. Medications: Complete as indicated. Supply adherence information that may be of importance to the receiving jurisdiction for appropriate patient management. Comments: Include any additional information relevant to patient care that will assist the new jurisdiction in assuring completion of therapy. Attach additional notes to this form if necessary. Follow-up:. Request `Follow-up' for TB patients who have started treatment in the State of Wisconsin.