Form 0920-1238 The EDN Tuberculosis Follow-Up Worksheet for Newly-Arriv

Form approved
OMB Control No. 0920-1238
Expiration Date XX/XX/XXXX

The EDN Tuberculosis Follow-Up Worksheet for Newly-Arrived Persons with Overseas Tuberculosis Classifications
A. Demographic
A1. Name (Last, First, Middle):

A6. Sex:

A5. Age:

A2. Alien #:

A3. Visa type:

A4. Initial U.S. entry date:

A7. DOB:

A8. TB Class Based on Technical Instructions for Panel Physicians:

___/___/______
A9. Country of examination:

A10. Country of birth:

A11a. Name in care of:

A12a. Sponsor agency name:

A11b. Phone number:

A12b. Phone number:

A11c. Address:

A12c. Address:

B. Jurisdictional Information
B1. Arrival jurisdiction:

B2. Current jurisdiction:

C. U.S. Evaluation
C1. Date of first U.S. test or provider/clinic visit:

_____/_____/________

Mantoux Tuberculin Skin Test (TST) in U.S.

No

Yes

C3a. Was IGRA performed in the U.S.?

C2a. Was a TST administered in the U.S.?
Yes

Interferon-Gamma Release Assay (IGRA) in U.S.

Unknown

If YES, C3b. Date collected:

If YES, C2b. TST placement date: ____/_____/__________

No

____/____/_____
_______ IUs/Spots

T-SPOT

QuantiFERON®
_____________

Unknown

Other, specify: __________________

C2d. TST interpretation:
Positive

C3d. Result:

C2e. History of Previous Positive TST:
No

Invalid

Unknown

Yes

Unknown

C4. Pre-immigration CXR available?
No

Negative

Unknown

Indeterminate,
Borderline, or
Equivocal

C3e. History of previous positive IGRA:

U.S Review of Pre-Immigration CXR

Yes

Positive

Negative

Unknown

Yes

Date unknown

C3c. IGRA brand:

Placement date uknown
C2c. TST mm:

Unknown

No

Unknown

U.S. Domestic CXR
C6a. U.S. domestic CXR done?
Yes

No

Unknown

If YES, C6b. Date of U.S. CXR: ____/____/_______

Comparison
C8. U.S. domestic
CXR comparison to
pre-immigration CXR:
Stable
Worsening

C5. U.S. interpretation of pre-immigration CXR:

C7. Interpretation of U.S. CXR:

Normal (Negative for TB)

Normal (Negative for TB)

Abnormal

Abnormal

Suggestive of TB

Suggestive of TB

Non-TB Condition

Non-TB Condition

Poor Quality/Not Interpretable

Poor Quality/Not Interpretable

Unknown

Unknown

Improving
Unknown

Public reporting burden of this collection of information is estimated to average 30 minutes per individual, 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
Information Collection Review Office, 1600 Clifton Road NE, MS D¬74, Atlanta, Georgia 30333; ATTN: PRA (0920-1238).

The EDN Tuberculosis Follow-Up Worksheet for Newly-Arrived Persons with Overseas Tuberculosis Classifications
Alien #
U.S. Review of Pre-Immigration Treatment
C9a. Completed treatment pre-immigration?

Yes

C9f. Standard TB treatment regimen was administered?

No

Standard TB treatment

Unknown
If YES, C9b.

Treated for TB disease

Unable to verify

Treated for LTBI

C10a. Arrived to the U.S. on treatment?

Treated, but unknown if TB disease or LTBI

Yes

If Treated for TB disease,
Treatment completed after panel physician diagnosis (DS 3030)

If YES, C10b.

At DGMQ-designated DOT site

Start date unknown

C9d. Treatment end date: ___/___/____

End date unknown

Yes

Treatment duration too short
Incorrect treatment regimen

Treatment documented on overseas medical history form (DS 3026)

Inadequate information provided

Documented on DS forms & patient reported at panel physician
examination

Lack of adequate diagnostics
Unknown DOT/adherence status

After U.S. arrival only, patient verbally reported
treatment completion
Unknown

2

3

No

If YES, C11b. Select all that apply:

C9e. Report of treatment administered prior to panel physician
examination:

C12. U.S. Microscopy/Bacteriology*
Date Collected

Undocumented/unverified treatment
Other, specify: ________________________

Sputa collected in U.S.?

Sputum Culture

Positive

Negative

Not Done

Unknown

___/___/_____

___/___/_____

Positive

Negative

Not Done

Unknown

Positive

Negative

Not Done

No *Covers all results regardless of sputa collection method.

Yes

AFB Smear

___/___/_____

Start date unknown

C11a: Pre-Immigration treatment concerns?

Other, specify:________________________________
C9c. Treatment start date: ___/___/____

Treated for LTBI

Treated for TB disease

C10c. Start date: ___/___/____

At non-DGMQ-designated DOT site

1

No

Unknown

Treatment completed prior to panel physician examination

#

Non-standard TB treatment

Unknown

Drug Susceptibility Testing
MDR-TB

Mono-RIF

Negative

Mono-INH

Other DR

Not Done

Unknown

No DR

Not Done

NTM

MTB Complex

MDR-TB

Mono-RIF

Contaminated

Negative

Mono-INH

Other DR

Not Done

Unknown

No DR

Not Done

NTM

MTB Complex

MDR-TB

Mono-RIF

Contaminated

Negative

Mono-INH

Other DR

Not Done

Unknown

No DR

Not Done

NTM

MTB Complex

Contaminated

D. Evaluation Disposition in U.S.
D1a. Evaluation disposition date in U.S.: ___/____/______

D1b. State/jurisdiction of evaluation disposition in U.S.: ______________

D2a. Evaluation disposition in U.S.:
Did not initate evaluation

Completed evaluation

Initiated Evaluation / Not completed

D2b. If evaluation was completed,
was treatment recommended?

D2c. If evaluation was NOT completed, why not? Select all that apply.

Yes
LTBI
Active TB

D3. Diagnosis

No

Lost to Follow-Up

Moved within U.S., transferred to:_______________________
State/jurisdiction
Moved outside U.S.

Refused Evaluation

Died

Unknown

Other, specify: _______________

Not Located

Class 0 - No TB exposure, not infected or Class 1 - TB exposure, no evidence of infection
Class 2 - TB infection, no disease
Class 4 - TB, inactive disease

Class 3 - TB, TB disease
Pulmonary
Culture-confirmed

Extra-pulmonary
Yes

Both sites
No

The EDN Tuberculosis Follow-Up Worksheet for Newly-Arrived Persons with Overseas Tuberculosis Classifications
Alien #
D4. If diagnosed with TB disease:

State Case Number:

RVCT # unknown*

RVCT Reported*

TBLISS # unknown*

TBLISS Reported*

Year

_____

_______________________________

State

RVCT # / TBLISS #

City/County Case Number:
Year

_____

_______________________________

State

RVCT # / TBLISS #

*Note: Either the RVCT or TBLISS number may be reported.
E. U.S. Treatment for TB Disease or TB Infection
E1a. U.S. treatment initiated:

Yes

No

Unknown

E1b. If NO, specify the reason. Select all that apply:
Patient declined against medical advice

Lost to follow-up

Died

Moved outside the U.S.

Currently on treatment

Treatment not offered based on
local clinic guidelines

Contraindication for treatment
E1c. If YES:

Treated for TB disease

E2. Treatment start date: ___/____/_______

Moved within U.S., transferred to:______________
State/jurisdiction
Prior treatment completed (year: _________)
Unknown
Other, specify:_____________________________

Treated for LTBI
E3. State/jurisdiction of treatment in U.S.: ______________

E4. Specify initial LTBI regimen:
Isoniazid (9 months; 9H)
Isoniazid (6 months; 6H)
Isoniazid/Rifapentine (3 months; 3HP)
Isoniazid/Rifampin (INH+RIF; 4 months)
Rifampin (4 months; 4R)
Isoniazid/Rifampin/Ethambutol/Pyrazinamide (RIPE; 2 months; suspected TB disease)
Unknown
Other, specify: _________________________________________________________
E5a. U.S. treatment completion status and dates:

Completed _____/_____/_________

Treatment ongoing

Treatment discontinued/stopped _____/_____/________

Unknown

*Completed refers to finished treatment, Treatment ongoing refers to treatment that is initiated but not yet completed. Treatment discontinued/stopped refers to
initiated treatment that is not completed.

If treatment discontinued/stopped, E5b. Specify the reason. Select all that apply:
Patient declined against medical advice
Died
Dying (treatment stopped because
of imminent death, regardless of cause
of death)
Provider decision
F. Evaluation Site Information
Provider’s Name:

Lost to follow-up
Moved outside the U.S.

Moved within U.S., transferred to:________
Unknown

Other, specify: ______________________

Adverse effect
Not TB disease
Pregnancy [For patient
diagnosed with LTBI]

Developed TB [For
patient diagnosed with
LTBI]

G. Treatment Site Information
Provider’s Name:

Clinic Name:

Clinic Name:

Telephone Number:

Telephone Number:
Same as evaluation site information

H. Comments

State/ jurisdiction