Free Interjurisdictional TB Notification - Follow-up, DPH 42011 - Wisconsin

DEPARMENT OF HEALTH AND FAMILY SERVICES Division of Public Health DPH 42011 (03/03)

STATE OF WISCONSIN (608) 266-9692 Fax: (608) 266-0049

INTERJURISDICTIONAL TB NOTIFICATION - FOLLOW-UP
Client Information is confidential under Wisconsin Statue 146.82 (1)

Status 30-day Located Not located Interim Report Final Report

Date Notification Received

RETURN FOLLOW-UP TO Contact Person - Name Address Jurisdiction Telephone Number (Include Area Code) PATIENT INFORMATION Patient - Name (Last , First, Middle Initial) Case Send F/U2 to reporting jurisdiction. RVCT Number Fax Number (Include Area Code) City State Zip Code

Date of Birth (mm/dd/yyyy)

Gender

Male

Female

Check the reason therapy stopped and provide the outcome date. If therapy is ongoing note comment section at bottom of form. Outcome date: Completed Moved New Address
City County State Zip Code

Telephone Number ( Lost (after initially located) Not TB Suspect / Source Case Finding Verified* by lab Other

) Never located Died *If verified and referring jurisdiction will submit the RVCT, complete Case outcome above Verified* by clinical definition Not verified Uncooperative or refused

Verified* by provider diagnosis

Contact Send local contact form, if follow-up performed No follow-up performed Evaluated: Never located LTBI/Convertors No follow-up performed Never located Comments: Started treatment Other Continuing treatment Completed treatment Started treatment Continuing treatment Current TB disease Previous TB disease Completed treatment No infecton

TB infection / no disease Other

SIGNATURE ­ Person Completing This Form

Date Signed

Print Name Jurisdiction Adapted with permission from the National Tuberculosis Controllers Association (NTCA 5-2002)

DPH 42011I (12/02)

INSTRUCTIONS FOR INTERJURISDICTIONAL TB NOTIFICATION - FOLLOW-UP
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 is to facilitate interstate 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 (LTBI). TB notification Follow-up forms 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). When to send the Interjurisdictional TB Notification Follow-up: 30-day status: At 30 days after notification was received, a status report should be sent to the referring jurisdiction. In instances when the patient is not located within 30 days, "lost" will be considered to represent the final disposition. If the patient is subsequently located, an update should be sent to the referring jurisdiction using the Follow-up form. DEFINITIONS Referring jurisdiction: The jurisdiction that initiates the Interjurisdictional notification. Case: A particular episode of clinically active TB. This is only used to refer to the disease itself, not the client with the disease. Verified Case: A clinically active TB disease case counted in original jurisdiction. Suspect: An illness marked by symptoms such as prolonged cough, prolonged fever, hemoptysis; chest radiographic or medical imaging findings; or laboratory tests that may be indicative of tuberculosis. F/U 2: The Follow-up 2 (F/U 2) is the national form used to report outcomes of verified cases to the CDC. RVCT: The Report of Verified Case of TB (RVCT) 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. Source Case Finding: Close associate to an 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. Contacts: An individual with close prolonged contact to AFB smear positive or smear negative pulmonary cases. Note: 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 PPD test results within a 2-year period. 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 as convertors or are not part of a contact investigation. Include specific risk factors for disease progression to assist receiving jurisdictions to prioritize follow-up. INSTRUCTIONS Date notification received: Receiving jurisdiction should indicate the date the Interjurisdictional Referral was received. Status: 30 days: At 30 days after notification was received, a status report should be sent to the referring jurisdiction indicating whether or not the patient was located. Interim: Send if an interim update in status is appropriate. Final status: Send when final status is known. Return Follow-up form to: The receiving jurisdiction should complete this information using the contact information provided on the original Interjurisdictional TB Notification referral form (or may use the Interjurisdictional Contact information from the NTCA Directory). Patient information: Complete as indicated Check appropriate patient status: Case: Check appropriate outcome for the patient. The F/U 2 should be sent to the reporting jurisdiction. The original reporting area will be responsible for getting F/U 2 results to the CDC. Suspect: The receiving jurisdiction will indicate whether the suspect case was verified, and if so, the method of verification. In some cases, the referring jurisdiction may still be the appropriate jurisdiction to report the case. If so, the receiving jurisdiction should also provide a final follow-up status and send a F/U 2 to the reporting jurisdiction. This section can also be used to provide follow-up information for individuals identified by a source case investigation. Contact: Some jurisdictions may not provide follow-up on all contact referrals and should indicate, "No follow-up performed" on the 30-day status report. If follow-up is performed, indicate the final outcome. Whenever possible, the receiving jurisdiction should attach contact follow-up information, including screening dates and results, as well as treatment dates and outcome. This will assist the referring area in completing contact information required by the CDC. LTBI: Some jurisdictions may not provide follow-up on all LTBI referrals and should indicate, "No follow-up performed" on the 30-day status report. If follow-up is performed and the patient is located, indicate the outcome. This section can also be used to provide follow-up information for convertors.