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pdfCureTB Contact/Source
Investigation (CI/SI) Notification
OMB APPROVED
CONTROL NO 0920-1186
EXP DATE: 06/30/2020
Reset Form
Division of Global Migration and Quarantine | E-mail: curetb@cdc.gov | Telephone: 619-542-4013 |
Fax For California: 619-692-8020 | Fax For other areas: 404-471-8905 | Web address: www.cdc.gov/usmexicohealth/curetb.html
¹Referring Jurisdiction:
¹Date sent:
City
County
¹Contact person:
¹Telephone:
Referring Agency:
Ext:
Fax:
E-Mail Address:
Index Patient Information for:
¹Name:
Contact Investigation
Paternal
Source Investigation
Maternal
First
Number
Street
County
Apt
State
M
F
City
Home Phone:
Zip code
Cell:
Tel:
Check if patient/parent not currently home. Current location:
Contact person Name:
Relationship:
Sex:
Middle
Parent’s Name (if child for SI):
DOB or Age:
Alias:
A. Index Patient Information
State
Home Phone:
Cell:
E-Mail Address:
Clinical Information:
Site(s) of disease:
²Date of
collection
Pulmonary
Meningeal
²Specimen type
²Smear
Disseminated
Culture
Other(s), specify:
Treatment:
Susceptibility
Drug
Sens
Res
Start Date:
Comments:
INH
RIF
EMB
PZA
Primary Address of Exposure
Diabetes
No Symptoms
Symptoms,specify:
Address:
Telephone:
Country:
Name
DOB or
Age
Relationship to
index Patient
Date Last
Exposure
Risk Factors
Phone #
(H=Home; C=Cell)
≤5
y/o
HIV/
AIDS
Immunosuppression
Sx
On
Tx
Sx
On
Tx
Address:
Other Address of Exposure
B. Contacts/Possible Sources
HIV
Telephone:
Country:
Name
DOB or
Age
Relationship to
index Patient
Date Last
Exposure
Phone #
(H=Home; C=Cell)
Risk Factors
≤5
y/o
HIV/
AIDS
Immunosuppression
Comments:
1. Fields required to initiate the referral process
2. Please send imaging and laboratory reports
as attachments
3. Please attach additional information, as needed.
Revised 05/2018
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: PRA 0920-004
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CS281360B
File Type | application/pdf |
File Title | CureTB Contact/Source Investigation (CI/SI) Notification |
Subject | CureTB, Contact, Source, Investigation, CI/SI, Notification, Form requested by: vbi1, Form development/508 compliance: vnm5 |
Author | DHHS/CDC/OD/OADC/DCS |
File Modified | 2018-12-13 |
File Created | 2018-05-01 |