Free 14058.pdf - Indiana

REPORT OF TUBERCULOSIS
State Form 14058 (R7/3-08)

2 North Meridian Street, Section 6-A

INDIANA STATE DEPARTMENT OF HEALTH

Indianapolis, IN 46204 (317) 233-7434

TB Law: Every suspected and verified case of tuberculosis disease must be reported to the local health officer within 72 hours (from probable diagnosis) in accordance with 410 IAC 1-2.3

1. Patient Name (Last, First, MI): ________________________________________________________________ 2. Address ______________________________________________________ ____________________________________________________________ Yes No City______________________ Within city limits: Phone (_____)________________________________________________ County_________________________ Zip Code____________________ 3. Date of birth ____-_____-_____ 4. At time of report: Alive Dead Male Female 5. Age______________________ 6. Sex: 7. Occupation (within past 12 months): Health Care Correctional Employee Student Retired Migrant/Seasonal Worker Unemployed Unknown Other Specify: _________________________________________________________ Place of Employment/School ____________________________________ 8. Race: Check all that apply White American Indian or Alaska Native Asian Multiracial Black or African-American Hawaiian Native or other Pacific Islander 9. Ethnic origin: Hispanic or Latino Not Hispanic or Latino

FOR LOCAL HEALTH DEPARTMENT USE ONLY Date received at local health department__________________________________________ Received by__________________________________Phone (____)________________ Reported by:_________________________________________________________________ Agency:_____________________________________________________________________ Phone _(______)________________________ Attending Physician:___________________________________________________________ Phone __(_____)______________________________________________________________ 12. Skin Test/Interferon Gamma Release Assay for MTB (IGRA) & TB disease history Mantoux test: Date given ______________ Date read___________ Results __________mm IGRA Test Type: ______________ Results ______________ Date Given_____________ Previous diagnosis of active TB? 13. HIV status Was HIV test offered? Positive Results: If positive, based on: Yes No If yes, year of diagnosis _______

Yes No 10. Born in the United States: If "No," what is the country of birth______________________________________ Immigration Status at first entry to the U.S. Immigrant Refugee Unkn

Date arrived in the U.S._______--____________(month/year) 11. Primary Reason Evaluated for TB Disease (Choose one) Contact to TB case TB Symptoms Abnormal Chest X-Ray Targeted Testing Health Care Worker Employment/Administrative Testing Immigration Medical Exam Other High-Risk Medical Condition: _________________________ Incidental Lab Result Other (explain): _______________________________________________
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Name of case _________________________________

Yes

No

Offered & Refused Pending Patient History No No No

Negative Indeterminate Medical Documentation Yes Yes Yes

14. Alcohol & drug use: Excess alcohol intake (within the past year)? Injecting drug use (within the past year)? Non-injecting drug use (within the past year)? History of methamphetamine use? Currently smoking tobacco? History of smoking tobacco?

Yes No Yes No Yes No (Continued on the back)

Patient name (Last, First, MI): ________________________________________________________________ 15. Additional Risk Factors (check all that apply): Contact of MDR-TB Patient Contact of Infectious TB Patient Missed Contact Incomplete LTBI Therapy Post-organ Transplantation Diabetes Mellitus End-Stage Renal Disease Immunosuppression (not HIV/AIDS) Other, specify: _________________________ None TNF- Antagonist Therapy Prior TST/IGRA Positive, Year tested:____

16. Has the patient been homeless within the past year? 17. Resident of long-term care facility at time of diagnosis? 18. Resident of correctional facility at time of diagnosis? 19. Any history of incarceration? 20. Clinical symptoms: Yes No

Yes Yes Yes

No No No

Facility name ______________________________________________________ Facility type/name __________________________________________________ Facility type/name __________________________________________________

Location and date of most recent incarceration: ______________________________________________ Hemoptysis Fatigue Chest pain Night sweats Fever Chills Other _______________________________ Date of onset of symptoms_____________ Previous Chest x-ray date (if known) _________________ Previous CT date (if known) _________________

Prolonged productive cough Weight loss Loss of appetite

21. Radiology Chest x-ray: Normal Abnormal* Not done Date of x-ray: ________________ Chest CT: Normal Abnormal* Not done Date of CT: __________________ *check `Abnormal', if the chest x-ray or chest CT showed any abnormality If abnormal: Cavitary Miliary If abnormal and compared to prior CXR/CT: Stable Other, consistent with TB Worsening

Improving Positive

Unknown Negative Positive Pending Negative

22. Laboratory specimens: Sputum only (dates collected) _____________________________ AFB smear results: Culture results: M. tuberculosis complex Pending Not identified Other

Specimens other than sputum (specify) __________________________________ (date collected) _______________ AFB smear results: Culture results: M. tuberculosis complex Pending Not identified Other Culture results: Molecular Analysis- Test Type: Laboratory performing the testing: 23. Disease site(s): Pulmonary Isoniazid Dose_______ GenProbe MTD PCR testing Result: Positive Negative

ISDH Laboratory Pleural

Other Laboratory _____________________________________________________________________

Lymphatic

Bone & Joint

CNS

Other (specify)_____________________ Other (specify) _______________________ Dose______ Vitamin B6 Dose______

24. Initial drug regimen:

Rifampin Pyrazinamide Dose_______ Dose________

Ethambutol Dose_______

Patient weight: ___________________ pounds / 2.2 = ___________________ Kg 25. Date therapy started _______________________ Requesting drugs through ISDH: Yes (submit prescription & drug request form) No

26. Infectious Period: beginning (3 months prior to start of symptoms): _____________________________ ending: _____________________________
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Instructions for Completing State Form 14058, "Report of Tuberculosis"
This form is for use for persons who have either been diagnosed with or are suspected of having active TB disease. Do not use this form for reporting persons with latent TB infection ("reactors"). The "For Local Health Department Use Only" should be completed when prior to forwarding to ISDH. The information directly under this box should be completed by the physician or hospital representative making the report. Items 1 & 2: complete each item. Do not leave blank. For patients who are in an institutional or correctional setting at the time of diagnosis, enter the address and county for the facility. Item 3: enter date of birth in "month-day-year" format, i.e., 11-14-28, or 11-14-1928. Items 4-7: complete each item. Item 4, check whether the patient is alive or dead at the time of diagnosis. If the patient was alive at the time medical care was sought and TB was at least suspected based on the differential diagnosis or by obtaining specimens for AFB smear and culture, check "Alive," regardless of whether or not TB medications were started. Check "Alive" even if the patient was not started on TB drugs and subsequently died before culture results became known. Item 7, indicate patients occupation(s) within the last 12 months (check all that apply). If the patient's occupation is not listed, please check other and specify. Items 8-10: each item should be completed and collected as self report. Check the patients self reported race and ethnicity. If the patient was not born in the U.S., enter the country of birth (this may or may not be the country they immigrated from), as well as the month and year of arrival in the U.S. Do not leave blank. Check the appropriate box if patient was born outside the U.S. and first entered the U.S. on a refugee or immigrant visa. If patient entered as any other visa category check unknown (Unkn). Item 11: check the primary reason (select only one) why the patient was evaluated for TB disease. Contact to TB case (check if evaluation was a result of contact investigation or source case finding), TB symptoms (check if evaluation was due to signs and symptoms, list all in item 20), Abnormal Chest x-ray (check if evaluation was due to abnormal cxr, list results in item 21), Targeted Testing (check if patient was part of a targeted testing screening program or specifically emigrated from an area of the world with high rates of TB), Health Care Worker (check if evaluation was done due to positive TST or Interferon Gamma Release Assay for MTB (IGRA) through baseline or annual testing), Employment/Administrative Testing (check if evaluation was a result of routine employment physical examination, employment TST requirement, or primary or secondary school routine TST testing), Immigration Medical Exam (check if evaluation was done as part of immigration application process either here in the U.S. or overseas, Other High-Risk Medical Condition (check if evaluation was a result of screening for other medical conditions, including HIV, organ transplant, etc.), or Incidental Lab Result (check if notification was a result of incidental specimen collected which was then found to be AFB smear positive or culture positive for MTB without suspicion of TB disease or when TB disease was not considered a possible diagnosis). Indicate Other if primary reason not listed. Item 12: enter the date given, date read and size of TST induration (in millimeters) or IGRA test (QFT-G, TSpot, etc) and the appropriate results (results and date administered/blood drawn). Item 13: enter the information on HIV testing. Do not leave blank. Item 14: check as appropriate. Indicate alcohol and drug use within the past 12 months. For alcohol, drug use, methamphetamine use and tobacco use, interview the patient, review the medical record, or both. Do not leave blank. Injecting and non-injecting drug use refers to the illicit use of prescription as well as illegal drugs. Examples of excess alcohol use are more than 5 or 6 drinks per occasion, binge drinking, evidence of DUI arrests, attendance at Alcoholics Anonymous meetings or residential or outpatient alcohol treatment centers. (Continued on back)

Item 15: Check all that apply. Indicate any additional TB risk factors that the TB patient may have. Contact of MDR-TB patient (check regardless of whether the MDR-TB case is infectious or not), Contact of Infectious TB patient (check if case is a contact to infectious TB patient), Missed Contact (if after having been diagnosed with TB disease the patient was found to have been a contact of a known TB patient within the last 2 years), Incomplete LTBI Therapy (check if patient was previously identified as having LTBI and was not treated completely for LTBI within the past 2 years), tumor necrosis factor-alpha TNF- Therapy (check if patient recently has, or recently had been receiving tumor necrosis factor-alpha therapy for treatment of rheumatoid arthritis or other selected autoimmune diseases), Post-organ transplant (check if the patient has a history of solid organ transplantation), Diabetes Mellitus (check if the patient has diabetes mellitus at the time of TB diagnosis), End-Stage Renal Disease (check if patient has end-stage renal disease or chronic renal failure at time of TB diagnosis), Immunosuppression (check if patient has immunosuppression due to either a medical condition or medication and not due to HIV), Prior TST/IGRA positive (check, and provide date, if patient had a prior TST/IGRA done), and Other (check if patient has other risk factors not included in the above choices. Items 16-19: example of long term care facilities are nursing homes, hospital-based extended care facilities, residential treatment centers, and group homes for the mentally retarded or developmentally disabled. Correctional facility includes local jails, state and federal prisons, work-release centers and juvenile correctional facilities (including detention centers, reception and diagnostic centers, residential treatment centers and halfway houses). If patient has a history of incarceration, indicate location and date of most recent event. Item 20: check all clinical symptoms that apply. Also include date of onset of first symptom or if chronic symptoms then date of worsening. Item 21: check CXR and CT results as appropriate. If comparisons to prior CXR or CT were made, indicate dates of comparison. Item 22: this is for sputum only, i.e., lung secretions coughed up by the patient, either unassisted or induced. Bronchial washings, trans-tracheal, endotracheal, and needle aspirates of pulmonary specimens are not sputum, and should be entered as specimens other than sputums. Molecular Analysis refers to a nucleic acid amplification test (GenProbe, MTD or PCR testing) that are performed directly on the specimen, not on the culture Item 23: check the appropriate disease site(s). Item 24: check each drug and provide dosage(s) prescribed by physician. Also, enter the patient's weight. Item 25: enter the date therapy was initially started. Item 26: enter the initial infectious period for all pulmonary/ pleural / and laryngeal patients. For these patients, the infectious period begins three months before symptom onset or first positive finding (e.g. abnormal chest radiograph) consistent with TB disease, whichever is longer. The infectious period is closed with: 1) effective treatment for >= 2 weeks, 2) diminished symptoms, and 3) mycobacterial response (smear negative). Providers: forward the completed form and prescriptions, if applicable, to your local health department. Do not send directly to the State Department of Health. Local health departments: forward to the State Department of Health TB Control Program. Include the drug order form, radiology, laboratory reports and a copy of the prescriptions, if applicable.