Completing the TB Follow-up Worksheet

Completing theTB Follow-up Worksheet

Indiana State Department of HealthFebruary 2009

Worksheet Objectives• The TB Follow-up Worksheet is designed to

– collect information on immigrants and refugees who have migrated to the US.• They were classified overseas during the required medical examination process with a TB condition.• Follow-up evaluation in the US was recommended.

• The TB Follow-up Worksheet is generated from the CDC’s Electronic Disease Notification(EDN) system by ISDH.

• ISDH sends the overseas medical information and TB Follow-up Worksheet to the Local Health Department (the county of the immigrant’s/refugee’s [I/R] residence).

• The Local Health Department submits the completed TB Follow-up Worksheet to ISDH within 30 days if possible.

• Information from the TB Follow-up Worksheet is entered into the EDN system by ISDH and then transferred electronically to CDC.

Indiana State Department of Health

The TB Follow-up WorksheetPage 1


The TB Follow-up WorksheetPage 2


Demographic InformationThis section is pre-populated by the EDN system. It includes the I/R’s demographic information.

If this section is blank, enter the Name, Alien # and DOB from the overseas medical forms. That is sufficient.Note: Alien # is an A followed by 8 or 9 digits.

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Jurisdictional InformationThis section is also pre-populated by EDN.It provides jurisdictional information based on the I/R’s U.S. address.

If this section is blank, no worries. Leave it blank.

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U.S. EvaluationThis section is for data entry of the medical evaluation performed in the U.S.C1 – Enter the date of the initial medical visit

C2a – Check the appropriate box (example of unknown – pt reports previous positive but has no documentation)

C2b – If C2a yes, enter the date the TST was placed.Please write the date the TST was read next to the placement date.

C2c – If C2a yes, write the mm size of the induration, ex – 0mm

C2d – If C2a yes, check the appropriate box based on induration size and risk factors

C2e – If client has documentation of a previous positive TST, check box and leave C2a-C2d blank

C3a – Check the appropriate box

C3b – If C3a yes, enter the date of the blood draw for the QFT

C3c – If C3a yes, check the appropriate box

NOTE: If there is no documentation of a previous positive TST, use the QFT for the TB screening if possible. (QFT not approved for use if <17 years old or HIV+)

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U.S. Review of Overseas CXR

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C4 – Check the appropriate boxNOTE: C4 is only yes if a clinician in the US reviewed the film/disc brought by the I/R from overseas. This information is not from the overseas medical forms.

C5 – If C4 yes, check the appropriate box

C6 – If C4 yes & C5 Abnormal, check the appropriate boxNOTE: If abnormality is other than what is listed in C10, check other and write the abnormality on the line.


Domestic CXR

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C7 – Check the appropriate box

C8 – If C7 yes, enter the date of the US Chest X-Ray

C9 – If C7 yes, check the appropriate box

C10 – If C7 yes & C9 Abnormal, check the appropriate boxNOTE: If abnormality is other than what is listed in C10, check other and write the abnormality on the line.


Comparison

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C11 - If C4 and C7 both yes, check the appropriate box.


U.S. Microscopy/Bacteriology

NOTE: In case of more than three sputums, record results of additional test(s) in Comments

NOTE: If additional tests other than the above were used, include them with corresponding results in Comments (Ex – 3 sputums are documented in C12, but there is also a bronch wash result to record).

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C12If no specimen (ex - sputums, bronch wash, etc), check box before “Specimen not collected in US”

If specimen collected, complete Lines 1-2-3 (one line for each specimen)Specimen Source – write source (ex – sputum)Date – write MM/DD/YYYY source was collectedAFB Smear Result – check appropriate boxCulture Result – check appropriate box (NTM=non tuberculous mycobacteria)Drug Resistance(DR) – check appropriate boxNOTE: Only check a box under DR if MTB Complex checked under Culture Result. Otherwise leave blank.

NOTE: Ideally collect 3 sputums at least 8 hours apart with one collected first thing in AM


Review of Overseas Treatment

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You will find this information on the overseas medical forms.

This section refers to treatment overseas for TB Disease (Active TB).NOTE: If the I/R was treated for TB infection (LTBI) overseas, please record this information in Comments


C14 – Check the appropriate box (if no) or boxes (if yes)



C17 - Check ’Yes’ if the U.S. medical evaluation raises concerns about inadequate or inappropriate drug regimen, drug doses, or treatment length for overseas treatment.NOTE: If C17 yes, record concerns in Comments


DispositionThis section is for entry of information following the completion of the I/R US medical evaluation.

D1 – Enter the date the evaluation was completed.

D2 – Check appropriate boxIf Completed... – check appropriate box and continue with sections D3 and E.

If Initiated... – check appropriate boxSubmit to ISDH now

NOTE: If patient moved, but you do not have a forwarding address, check Lost to Follow-up.If reason is other than what is listed, check other and write the reason on the line.

If Did Not Initiate... – check appropriate boxSubmit to ISDH now

NOTE: If patient moved, but you do not have a forwarding address, check Lost to Follow-up.If reason is other than what is listed, check other and write the reason on the line.

D3 – Check appropriate boxNOTE: If Class 3, check appropriate box

D4 - Leave blank

D5 – Leave blank

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U.S. TreatmentThis section is for entry of information regarding tuberculosis treatment provided to I/R in the US

E1 – Check appropriate boxIf No Treatment submit to ISDH now

E2 – If E1 is Active Disease or LTBI, write MM/DD/YYYY that I/R started treatment.If treatment started submit to ISDH nowWrite estimated date of completion in Comments

E3 – Check appropriate boxIf no, re-submit to ISDH now

E4 – If E3 yes, write MM/DD/YYYY that I/R finished treatment.Re-submit to ISDH now

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CommentsF - Enter comments as desired.

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Physician Signature

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G – The worksheet data are sent to CDC electronically; therefore, the physician’s signature is not required. Please write the Physician’s name who did the evaluation.


Documents

Completing the TB Follow-up Worksheet