Form 0920-0600 Att C M tuberculosis Results Worksheet

CDC Model Performance Evaluation Program (MPEP) for Mycobacterium tuberculosis Drug Susceptibility Testing

Attachment C

M. tuberculosis Results Worksheet

MPEP Mycobacterium tuberculosis Results Worksheet

Public reporting burden of this collection of information is estimated to average 30 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; Attn: OMB-PRA (0920-0600)

Enter your drug susceptibility test results for each culture by using the data entry forms below.  There are separate forms for conventional vs molecular drug results. You can either enter your results directly on the forms or print them out to enter results manually.

Conventional Drug Susceptibility Worksheet for Culture:      

Drug	Resistant	Susceptible	Borderline	Contaminated	No Growth	Not Done
Rifampin
Isoniazid low
Isoniazid high
Pyrazinamide
Ethambutol
Streptomycin
Ethionamide
Rifabutin
Amikacin
Kanamycin
Capreomycin
Ciprofloxacin
Levofloxacin
Ofloxacin
Moxifloxacin
Cycloserine
Para-Amino Salicyclic Acid

Molecular Results Worksheet for Culture:      

Drug	Mutation Detected	Mutation Not Detected	No Result	Not Done
Rifampin
Isoniazid
Pyrazinamide
Ethambutol
Streptomycin
Ethionamide
Rifabutin
Amikacin
Kanamycin
Capreomycin
Ciprofloxacin
Levofloxacin
Ofloxacin
Moxifloxacin
Cycloserine
Para-Amino Salicyclic Acid