Attachment 13 E-mail or Fax Contact Form

#13 FAX Contact.doc

Centers for Disease Control and Prevention Performance Evaluation Program for Mycobacterium Tuberculosis/Non-tuberculosis Mycobacteria Drug Susceptibility Testing Program

Attachment 13 E-mail or Fax Contact Form

OMB: 0920-0600

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0920-0600 can be found here:

Document [doc]

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Attachment #9

Example:

M. tuberculosis/NTM Results Form – NTM Supplemental Information

Strain O – M. marinum Case History

Patient:

39-years old

Gender:

Male

Medical History:

HIV-positive

Current Ailment/Complaint:

Developed multiple cutaneous nodules on his hand and forearm

Patient Hobbies:

Maintains a tropical fish aquarium

Physician Notes:

Because of his current anti-retroviral therapy, the physician does not wish to use a rifampin-containing regimen and asks for susceptibility testing to be performed on this isolate of Mycobacterium marinum.

NTM Supplemental Information Page

File Type	application/msword
File Title	PERFORMANCE EVALUATION PROGRAM: DRUG SUSCEPTIBILITY TESTING OF STRAINS OF MYCOBACTERIUM TUBERCULOSIS_RESULTS FORM
Last Modified By	Suzette
File Modified	2006-08-30
File Created	2006-08-30