Completing the TB Follow-up Worksheet

1. Completing theTB Follow-up Worksheet Indiana State Department of Health

2. Worksheet Objectives • The TB Follow-up Worksheet is designed to • collect information on immigrants and refugees who have migrated to the US. • They were classified overseas during the required medical examination process with a TB condition. • Follow-up evaluation in the US was recommended. • The TB Follow-up Worksheet is generated from the CDC’s Electronic Disease Notification(EDN) system by ISDH. • ISDH sends the overseas medical information and TB Follow-up Worksheet to the Local Health Department (the county of the immigrant’s/refugee’s [I/R] residence). • The Local Health Department submits the completed TB Follow-up Worksheet to ISDH within 30 days if possible. • Information from the TB Follow-up Worksheet is entered into the EDN system by ISDH and then transferred electronically to CDC. Indiana State Department of Health

3. The TB Follow-up Worksheet Page 1 Indiana State Department of Health

4. The TB Follow-up Worksheet Page 2 Indiana State Department of Health

5. Demographic Information This section is pre-populated by the EDN system. It includes the I/R’s demographic information. If this section is blank, enter the Name, Alien # and DOB from the overseas medical forms. That is sufficient. Note: Alien # is an A followed by 8 or 9 digits. Page 1 Indiana State Department of Health

6. Jurisdictional Information This section is also pre-populated by EDN. It provides jurisdictional information based on the I/R’s U.S. address. If this section is blank, no worries. Leave it blank. Page 1 Indiana State Department of Health

7. U.S. Evaluation This section is for data entry of the medical evaluation performed in the U.S. C1 – Enter the date of the initial medical visit C2a – Check the appropriate box (example of unknown – pt reports previous positive but has no documentation) C2b – If C2a yes, enter the date the TST was placed. Please write the date the TST was read next to the placement date. C2c – If C2a yes, write the mm size of the induration, ex – 0mm C2d – If C2a yes, check the appropriate box based on induration size and risk factors C2e – If client has documentation of a previous positive TST, check box and leave C2a-C2d blank C3a – Check the appropriate box C3b – If C3a yes, enter the date of the blood draw for the QFT C3c – If C3a yes, check the appropriate box NOTE: If there is no documentation of a previous positive TST, use the QFT for the TB screening if possible. (QFT not approved for use if <17 years old or HIV+) Page 1 Indiana State Department of Health

8. U.S. Review of Overseas CXR C4 – Check the appropriate box NOTE: C4 is only yes if a clinician in the US reviewed the film/disc brought by the I/R from overseas. This information is not from the overseas medical forms. C5 – If C4 yes, check the appropriate box C6 – If C4 yes & C5 Abnormal, check the appropriate box NOTE: If abnormality is other than what is listed in C10, check other and write the abnormality on the line. Page 1 Indiana State Department of Health

9. Domestic CXR C7 – Check the appropriate box C8 – If C7 yes, enter the date of the US Chest X-Ray C9 – If C7 yes, check the appropriate box C10 – If C7 yes & C9 Abnormal, check the appropriate box NOTE: If abnormality is other than what is listed in C10, check other and write the abnormality on the line. Page 1 Indiana State Department of Health

10. Comparison C11 - If C4 and C7 both yes, check the appropriate box. Page 1 Indiana State Department of Health

11. U.S. Microscopy/Bacteriology C12 If no specimen (ex - sputums, bronch wash, etc), check box before “Specimen not collected in US” If specimen collected, complete Lines 1-2-3 (one line for each specimen) Specimen Source – write source (ex – sputum) Date – write MM/DD/YYYY source was collected AFB Smear Result – check appropriate box Culture Result – check appropriate box (NTM=non tuberculous mycobacteria) Drug Resistance(DR) – check appropriate box NOTE: Only check a box under DR if MTB Complex checked under Culture Result. Otherwise leave blank. Page 1 NOTE: Ideally collect 3 sputums at least 8 hours apart with one collected first thing in AM NOTE: In case of more than three sputums, record results of additional test(s) inComments Indiana State Department of Health NOTE: If additional tests other than the above were used, include them with corresponding results in Comments (Ex – 3 sputums are documented in C12, but there is also a bronch wash result to record).

12. Review of Overseas Treatment You will find this information on the overseas medical forms. This section refers to treatment overseas for TB Disease (Active TB). NOTE: If the I/R was treated for TB infection (LTBI) overseas, please record this information in Comments C13 – Check the appropriate box C14 – Check the appropriate box (if no) or boxes (if yes) C15 – Check the appropriate box C16 – Check the appropriate box C17 - Check ’Yes’ if the U.S. medical evaluation raises concerns about inadequate or inappropriate drug regimen, drug doses, or treatment length for overseas treatment. NOTE: If C17 yes, record concerns in Comments Page 2 Indiana State Department of Health

13. Disposition This section is for entry of information following the completion of the I/R US medical evaluation. D1 – Enter the date the evaluation was completed. D2 – Check appropriate box If Completed... – check appropriate box and continue with sections D3 and E. If Initiated... – check appropriate box Submit to ISDH now NOTE: If patient moved, but you do not have a forwarding address, check Lost to Follow-up. If reason is other than what is listed, check other and write the reason on the line. If Did Not Initiate... – check appropriate box Submit to ISDH now NOTE: If patient moved, but you do not have a forwarding address, check Lost to Follow-up. If reason is other than what is listed, check other and write the reason on the line. D3 – Check appropriate box NOTE: If Class 3, check appropriate box D4 - Leave blank D5 – Leave blank Page 2 Indiana State Department of Health

14. U.S. Treatment This section is for entry of information regarding tuberculosis treatment provided to I/R in the US E1 – Check appropriate box If No Treatment submit to ISDH now E2 – If E1 is Active Disease or LTBI, write MM/DD/YYYY that I/R started treatment. If treatment started submit to ISDH now Write estimated date of completion in Comments E3 – Check appropriate box If no, re-submit to ISDH now E4 – If E3 yes, write MM/DD/YYYY that I/R finished treatment. Re-submit to ISDH now Page 2 Indiana State Department of Health

15. Comments F - Enter comments as desired. Page 2 Indiana State Department of Health

16. Physician Signature Page 2 G – The worksheet data are sent to CDC electronically; therefore, the physician’s signature is not required. Please write the Physician’s name who did the evaluation. Indiana State Department of Health