NEW JERSEY TUBERCULOSIS CASE, SUSPECT AND STATUS REPORT

SHADED AREAS ARE FOR STATE USE ONLY; LEAVE BLANK.	TB-70
Type of Report: Initial Recurrence Current Status
Patient’s Name (Last, First, MI)

4. Street Address: (Check if New )	Within City Limits: Yes No

Telephone:	County:

City:	State:	Zip Code:

Municipal Code:

1. Date Reported (mm/dd/yyyy)

3. CASE NUMBERS:	REASON:
Year	Identification

Reported	State	Number
STATE CASE NO.:
2. Date Submitted

Month	Day	Year	LINKING CASE NO.:
_
LINKING CASE NO.:
_

5. Count Status: (select one)

Count as a TB case

Noncountable TB Case

Suspect

Counted by another US area

TB treatment initiated in another country

Specify: ____________

Recurrent TB within 12 months after completion of therapy	8. Date of Birth:

10. Race: (select all that apply)

American Indian or Alaska Native

Asian: (specify)

Black or African American

Native Hawaiian or other Pacific Islander:

Specify _______________________

White
9. Sex at Birth

Male

Female
6. Date Counted:

Month	Day	Year	11. Ethnicity:

Hispanic or Latino

Not Hispanic or Latino	12. Country of Birth:

U.S. Born (or born abroad to a parent

who was a U.S. Citizen: (select one) Yes No

Country of Birth: ________________________
7. Previous Diagnosis of TB Disease: (select one)

Yes No

If YES, enter year of previous TB Diagnosis:

13. Month-Year Arrived in US:

-

14. Pediatric TB Patients (<15 years old):

Country of birth for primary Guardian(s): (specify)

Guardian 1: ______________________________

Guardian 2: ______________________________

Patient lived outside the U.S. for >2 months?

Yes No Unknown

If Yes, list countries (specify): ____________________	16. Site of TB Disease (select all that apply)

Pulmonary	Bone and/or Joint

Pleural	Genitourinary

Lymphatic: Cervical	Meningeal

Lymphatic: Intrathoracic	Peritoneal

Lymphatic: Axillary	Site not stated

Lymphatic: Other	Laryngeal

Lymphatic: Unknown

Other (Specify): ____________________	(state use only)

1

2

3
15. Status at TB Diagnosis (select one)

Alive Dead

If Dead, enter date of death:

If Dead, was TB the cause of Death?

Yes No Unknown
NEW JERSEY TUBERCULOSIS CASE, SUSPECT AND STATUS REPORT

(Continued)
Patient Name

Case Number

Date

17. Sputum Smear: (select one)

Positive	Not Done Date Collected:

Negative	Unknown	17a. Sputum Smear: (select one)

Positive	Not Done Date Collected:

Negative	Unknown
18. Sputum Culture: (select one)

Positive	Not Done Date Collected:

Negative	Unknown Date Reported:

Laboratory (specify):	18a. Sputum Culture: (select one)

Positive	Not Done Date Collected:

Negative	Unknown Date Reported:

Laboratory (specify):
19. Smear/Pathology/Cytology of Tissue and Other Body Fluids: (select one)

Positive	Not Done Date Collected:

Negative	Unknown

Type of Exam (select all that apply):

Smear	Pathology/Cytology

Source (specify):	19. Smear/Pathology/Cytology of Tissue and Other Body Fluids: (select one)

Positive	Not Done Date Collected:

Negative	Unknown

Type of Exam (select all that apply):

Smear	Pathology/Cytology

Source (specify):	Anatomic

Code

20. Culture of Tissue and Other Body Fluids: (select one)

Positive	Not Done	Date Collected:

Negative	Unknown	Date Reported:

Source (specify):

Lab:	20a. Culture of Tissue and Other Body Fluids: (select one):

Positive	Not Done	Date Collected:

Negative	Unknown	Date Reported:

Source (specify):

Lab:	Anatomic

Code

21. Nucleic Acid Amplification Test Result: (select one)

Positive	Not Done Date Collected:

Negative	Unknown Date Result Reported:

Indeterminate

Enter specimen type: Sputum OR if not sputum, specify:

Source (specify):

Laboratory (specify):	Anatomic

Code

22. Chest Radiograph and Other Chest Imaging Study

22A. Initial Chest Radiograph:	Date:	(select one) Normal Abnormal * Not Done Unknown

* For ABNORMAL Initial Chest Radiograph:

Evidence of a cavity? (select one)	Yes No Unknown

Consistent with TB? (select one)	Yes No Unknown

Evidence of miliary TB? (select one)	Yes No Unknown

22B. Initial Chest CT Scan or

Other Chest Imaging Study:	Date:	(select one) Normal Abnormal * Not Done Unknown

* For ABNORMAL Initial Study:

Evidence of a cavity? (select one)	Yes No Unknown

Consistent with TB? (select one)	Yes No Unknown

Evidence of miliary TB? (select one)	Yes No Unknown

22C. Follow up Chest Radiograph,

CT Scan or Other Chest

Imaging Study:	Date:	Chest (select one) Improved Worsening Stable

CT Scan Other (specify):

23.Tuberculin (Mantoux) Skin Test at Diagnosis: (select one)

Positive	Not Done

Negative	Unknown

Date Test Placed: Millimeters Induration:	25. Primary Reason Evaluated for TB Disease

(select one)

TB Symptoms

Abnormal Chest Radiograph (incidental)

Contact Investigation

Targeted Testing

Health Care Worker

Employment/Administrative Testing

Immigration Medical Exam

Incidental Lab Result

Unknown
24. Interferon Gamma Release Assay for Mycobacterium Tuberculosis at Diagnosis: (select one)

Date Collected:

Positive	Not Done

Negative	Unknown

Indeterminate	Test Type (specify):
NEW JERSEY TUBERCULOSIS CASE, SUSPECT AND STATUS REPORT

(Continued)
Patient Name

Case Number

Date

26. HIV Status at Time of Diagnosis: (select one)

Negative	Indeterminate	Not Offered	Unknown

Positive	Refused	Test Done Results Unknown	State Patient Number:

27. Homeless Within The Past Year? (select one)

No

Yes

Unknown	28. Resident of Correctional Facility at Time of Diagnosis? (select one)

No Yes Unknown

If Yes: (select one)

Federal Prison	Local Jail	Other Correctional Facility	If Yes, under the custody

of Immigration and

State Prison	Juvenile Correctional Facility	Unknown	Customs Enforcement?

Name of Facility:	No	Yes
29. Resident of Long-Term Care Facility at Time of Diagnosis? (select one)

No Yes Unknown

If Yes: (select one)

Nursing Home	Residential Facility	Alcohol or Drug Treatment Facility	Unknown

Hospital-based Facility	Mental Health Residential Facility	Other Long Term Care Facility

Name of Facility:
30. Primary Occupation Within the Past Year (select one)

Health Care Worker Migrant/Seasonal Worker Retired Not Seeking Employment (e.g. student, homemaker, disabled)

Correctional Facility Employee Unemployed Unknown Other (specify):
31. Injecting Drug Use Within Past Year

(select one)

No Yes Unknown	32. Non-Injecting Drug Use Within Past Year (select one)

No Yes Unknown	33. Excess Alcohol Use Within Past Year

(select one)

No Yes Unknown
34. Additional TB Risk Factors (select all that apply)

Contact of MDR-TB Patient	Incomplete LTBI Treatment	Diabetes Mellitus	Other (Specify)

(2 years or less)

Contact of Infectious TB Patient	TNF-a Antagonist Therapy	End Stage Renal Disease	None

(2 years or less)

Missed Contact (2 years or less)	Post-organ Transplantation	Immunosuppression (not HIV/AIDS)
35. Immigration Status at First Entry to the U.S. (select one)

Immigrant Visa	Tourist Visa	Asylee or Parolee

Student Visa	Family Fiancé Visa	Other Immigration Status

Not Applicable	Employment Visa	Refugee	Unknown

* U.S. Born (or born abroad to a parent that was a U.S. Citizen)

* Born in one of the U.S. Territories, U.S. Island Areas or U.S. Outlying Areas

36. Initial Therapy Started

mm/dd/yyyy

________________

36a. Current Therapy *

mm/dd/yyyy	37. Initial Drug Regimen	37A. Current Drug Regimen

mg	mg	mg

Isoniazid	_____	Ethionamide	_____	Moxifloxacin	_____

Rifampin	_____	Amikacin	_____	Cycloserine	_____

Pyrazinamide	_____	Kanamycin	_____	Para-Amino

Ethambutol	_____	Capreomycin	_____	Salicylic Acid	_____

Streptomycin	_____	Ciprofloxacin	_____	Other	_____ mg

Rifabutin	_____	Levofloxacin	_____	Other	_____ mg

Rifapentine	_____	Ofloxacin	_____

Patient’s Weight:	_____ lbs.

_____ kg.

*Please document current drug regimen changes and discontinued medications
NEW JERSEY TUBERCULOSIS CASE, SUSPECT AND STATUS REPORT

(Continued)
Patient Name

Case Number

Date

UD7.	Hospitalization

Hospital Name:	Telephone:

Medical Record #:	Admission Date:	Discharge Date:
I. Diagnosing Physician

Name:	Telephone:

City:	State:
II. Other Physician

Name:	Telephone:

City:	State:
III. Case Manager

Name:	Telephone:
UD8. Supervision is NOW being provided by

Health Dept.	Private/Hospital/Hosp. Clinic/Institution	Both HD and Private

Name:	Telephone:

City:	State:
Report Prepared By

Name:	Telephone:	Date:

Remarks:

Signature: (not legal unless signed)
NEW JERSEY TUBERCULOSIS CASE, SUSPECT AND STATUS REPORT

(Continued)
Patient Name

Case Number

Date

Follow up 1

38. Genotyping Accession Number

Isolate submitted for genotyping? Yes No

If YES, genotyping Accession Number for episode:
39. Initial Drug Susceptibility Testing:

Was drug susceptibility testing done? (select one)

No Yes Unknown

Date first isolate collected for which drug susceptibility was done:

mm/dd/yyyy

Enter specimen type:

Sputum OR if not sputum:

Specify Source:	39a. Other Drug Susceptibility Testing:

Was drug susceptibility testing done? (select one)

No Yes Unknown

Date first isolate collected for which drug susceptibility was done:

_____

mm/dd/yyyy

Enter specimen type:

Sputum OR if not sputum:

Specify Source:	Anatomic

Code

40. Drug Susceptibility Results (select one)

Initial Other

(Select one option for each drug checked)

Resistant	Sensitive	Not Done	Unknown	Resistant	Sensitive	Not Done	Unknown

Isoniazid	Capreomycin

Rifampin	Ciprofloxacin

Pyrazinamide	Levofloxacin

Ethambutol	Ofloxacin

Streptomycin	Moxifloxacin

Rifabutin	Other Quinolones

Rifapentine	Cycloserine

Ethionamide	PAS

Amikacin	Gatifloxacin

Kanamycin	Other drug

Specify:

Other drug

Specify:

Specify Lab:
Follow up 2

41.Sputum Culture Conversion Documented (select one)

No Yes Unknown
If yes, enter date specimen collected for FIRST consistently negative sputum culture:

mm/dd/yyyy	If no, enter reason for not documenting sputum culture conversion: (select one)

Clinically Improved	Patient refused	Patient lost to follow up

No follow-up sputum collected	Other Specify:

Died	Unknown
42. Moved (Must Include Address)

New Address:

Did the patient move during TB therapy: No Yes

Phone #:

If YES, moved to where: (select all that apply)

In state, out of jurisdiction (enter city/county)	Specify Specify

Out of state (enter state)	Specify Specify

Out of the U.S. (enter country)	Specify Specify

If moved out of the U.S., transnational referral? (select one) No Yes
43. Date Therapy Stopped:

mm/dd/yyyy	44. Reason Therapy Stopped or Never Started (select one)

Completed therapy	Not TB	If Died, Indicate Cause of Death: (select one)

Lost	Died	Related to TB disease	Unrelated to TB disease

Uncooperative or refused	Other	Related to TB therapy	Unknown

Adverse treatment event	Unknown

NEW JERSEY TUBERCULOSIS CASE, SUSPECT AND STATUS REPORT

(Continued)
Patient Name

Case Number

Date

Follow up 2 (Continued)

45. Reason Therapy Extended >12 Months: (select all that apply)

Rifampin resistance	Non-adherence	Clinically indicated – other reasons

Adverse drug reaction	Failure	Other (specify)
46. Type of Outpatient Health Care Provider: (select all that apply)

Local/State Health Department	IHS, Tribal HD, or Tribal Corp.	Inpatient care only	Unknown

Private Outpatient	Institutional/Correctional	Other
47. Directly Observed Therapy (DOT): (select one)

No, Totally Self Administered	Yes, Totally Directly Observed	Yes, Both Directly Observed and Self Administered

Unknown

Number of Weeks of Directly Observed Therapy (DOT):
48. Follow-up Drug Susceptibility Testing:

Was follow-up drug susceptibility testing done? No Yes Unknown

If No or Unknown, do not complete the rest of the form.
If Yes: Enter date last isolate collected for which drug susceptibility testing was done:

mm/dd/yyyy

Enter specimen type:	Sputum OR if not sputum, specify:
49. Last (Final) Drug Susceptibility Results (select one option for each drug)

Resistant	Sensitive	Not Done	Unknown	Resistant	Sensitive	Not Done	Unknown

Isoniazid	Capreomycin

Rifampin	Ciprofloxacin

Pyrazinamide	Levofloxacin

Ethambutol	Ofloxacin

Streptomycin	Moxifloxacin

Rifabutin	Other Quinolones

Rifapentine	Cycloserine

Ethionamide	PAS

Amikacin	Gatifloxacin

Kanamycin	Other drug

Specify:

Other drug

Specify:

Lab:

Report prepared by

Name:	Telephone:	Date:
Remarks:

Signature: (not legal unless signed)

4

TB-70

SEP 15	Page 6

SEP 15	Page 1

TB-70

ewhite

2015-09-04

NJDOH