DTBE/FSB Rifampin (RIF) Email Assessment

Form approved
OMB #0920-1027
Expiration date 08/31/2023

DTBE/Field Services Branch Rifampin (RIF) Assessment

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; 1600 Clifton Road NE, MS D- 74, Atlanta, Georgia 30333; Attn: OMB-PRA (0920-1027)

*Please print legibly.

Program Area (State/Large City/Territory): _________________________________________

Date: _____________________

1. Does your program have an inadequate supply of Rifampin 150 and 300 mg tablets?

□ Yes

□ No (if No, skip to Question 5)

□ I don’t know (if “I don’t know,” find out who does)

2. If so, is this inadequate supply affecting patients being treated for:

LTBI: □ Yes □ No □ I don’t know

TB disease: □ Yes □ No □ I don’t know

Both: □ Yes □ No □ I don’t know

3. If so, which of the following measures, if any, have you implemented to respond to the inadequate supply?

a. Switching patients to alternative medications:

LTBI: □ Yes □ No □ I don’t know

TB disease: □ Yes □ No □ I don’t know

Both: □ Yes □ No □ I don’t know

b. Obtaining Rifampin tablets from another jurisdiction:

□ Yes □ No □ I don’t know

c. Prioritizing some patients to receive rifampin for treatment of latent TB infection over others:

□ Yes □ No □ I don’t know

d. Other, please list: ______________________________________

4. If your program has prioritized some patients to receive Rifampin for LTBI over others, have any patients been denied treatment to date?

□ Yes

□ No (if No, skip to Question 5)

□ I don’t know (if “I don’t know”, find out who does)

□ Not applicable (program has not prioritized)

5. Approximately, how much Rifampin does your program have available?

a. ______ bottles of 300 mg tabs/30 tabs per bottle

b. ______ bottles of 300 mg tabs/100 tabs per bottle

c. ______ bottles of 300 mg tabs/____ tabs per bottle

□ I don’t know (if “I don’t know,” who does? _______________________

6. When will you run out of Rifampin?

□ Within the next week

□ Within the next month

□ Within the next 3 months

□ Within the next year

□ After one year

7. How many patients with active TB are currently on Rifampin?

8. How many patients with LTBI are currently on Rifampin?