Get Tb Notification Form 2011-2024

Centers for Disease Control and Prevention Division of Tuberculosis Elimination INTERNATIONAL TUBERCULOSIS NOTIFICATION FORM TO Health Officer Physician or Tuberculosis Control Personnel of Country Province District City or Village The individual named below has active tuberculosis and was treated in the USA. He or she has not completed treatment. This form is to notify you so that treatment can be completed. Tuberculosis Patient s Name Date of Birth Place of Birth Sex This patient informed us that he/she was going to the following location Patient s Address District Province Telephone if available e-mail address if available Contact person at this location If you have any questions contact the following person who treated this patient in the United States Name Address City State Zip Code Phone fax email Date of diagnosis of current illness This illness was a New episode of TB check one Treated for TB in the past before the current episode If previously treated describe the patient s prior history of tuberculosis and treatment. Centers for Disease Control and Prevention Division of Tuberculosis Elimination INTERNATIONAL TUBERCULOSIS NOTIFICATION FORM TO Health Officer Physician or Tuberculosis Control Personnel of Country Province District City or Village The individual named below has active tuberculosis and was treated in the USA. He or she has not completed treatment. This form is to notify you so that treatment can be completed* Tuberculosis Patient s Name Date of Birth Place of Birth Sex This patient informed us that he/she was going to the following location Patient s Address District Province Telephone if available e-mail address if available Contact person at this location If you have any questions contact the following person who treated this patient in the United States Name Address City State Zip Code Phone fax email Date of diagnosis of current illness This illness was a New episode of TB check one Treated for TB in the past before the current episode If previously treated describe the patient s prior history of tuberculosis and treatment. Revised 08 June 2011 Page 1 of 2 Site s of disease Pulmonary Extra-pulmonary specify Initial and most recent laboratory and radiographic test results microscopy cultures drug susceptibility test results radiographs and other critical lab tests use additional pages as needed Date Test Result Current Medications generic name Dose Frequency Route of Administration Start Date Drug Dose Frequency Route Start Date Treatment Plan* Our treatment plan for this patient is specified below. This may differ from TB treatment in your country. Please insure this patient completes a full course of treatment. He or she has not completed treatment. This form is to notify you so that treatment can be completed* Tuberculosis Patient s Name Date of Birth Place of Birth Sex This patient informed us that he/she was going to the following location Patient s Address District Province Telephone if available e-mail address if available Contact person at this location If you have any questions contact the following person who treated this patient in the United States Name Address City State Zip Code Phone fax email Date of diagnosis of current illness This illness was a New episode of TB check one Treated for TB in the past before the current episode If previously treated describe the patient s prior history of tuberculosis and treatment. Revised 08 June 2011 Page 1 of 2 Site s of disease Pulmonary Extra-pulmonary specify Initial and most recent laboratory and radiographic test results microscopy cultures drug susceptibility test results radiographs and other critical lab tests use additional pages as needed Date Test Result Current Medications generic name Dose Frequency Route of Administration Start Date Drug Dose Frequency Route Start Date Treatment Plan* Our treatment plan for this patient is specified below.