Author: administrator.laptop
Company: DPH

Massachusetts Department of Public Health
Bureau of Infectious Disease
Office of Integrated Surveillance and Informatics Services
305 South Street, Room 563, Jamacia Plain, MA 02130
Phone: 617-983-6801 Confidential Fax: 617-983-6220

LATENT TUBERCULOSIS INFECTION REPORTING FORM – CONFIDENTIAL

DEMOGRAPHIC INFORMATION

Patient Name: ____________________________________________________________
                                         Last                                                First                          
Patient Phone: (____)______ -____________          Date of Birth:   ____ / ____/ _______   
                                                                                                                  mm      dd       yyyy
Patient Address:__________________________________________________________
		                                                       Street
                          _________________________              ____               __________
                                        City	                                          State                      ZIP  

Country of Birth _____________________    Date of Entry into US: ____/ ____/ ______     
                                                                                                                    mm       dd       yyyy
Sex: (Circle One) 	Race:	(Circle one)			Hispanic:	Unique
Male			American Indian/Alaskan native	Yes		Address
Female			Native Hawaiian/Pacific Islander	No		Condition:
Transgender		Asian					Unknown	Incarcerated
Unknown		White							Homeless
			Black/African American
			Unknown

DIAGNOSTIC INFORMATION
        Interpretation:
Mantoux test (TST administered: ____/ ____/ ______    Results(mm) ______  (Circle one)                                                                        
				            mm      dd      yyyy			            Positive
											Negative
---------------------------------------------------------------------------------------------------------------------
										Interpretation:
IGRA administered:                     ____/ ____/ ______          		(Circle one)
(Quantiferon/T-spot)                              mm      dd       yyyy                     	Positive	Indeterminate
									Negative	Not Done
RISK AND TREATMENT INFORMATION
Risk Factors: (Check all that apply)
□	Close contact to a person with active TB disease within the past 2 years (Name: _____________)
□	Child 4 years of age or under
□	Visit outside the US >1 month within the past 5 years excluding Australia and Western Europe
□	Medical risks for progressing to active TB disease (see list in instructions)
□	Health care worker
□	Mycobacteria laboratory worker
□	Resident of high risk congregate setting

Evaluation/Treatment Plan

□	Refer for evaluation (where): ________________________________________________

□	Not Treat ----------> Why (circle one): Pregnant  / ABN ALT / Prev. Tx.  /Declined/Refused 
  Other(specify) ________________________
□	Treat (on-Site)

Reporting Provider

__________________________________________________   Date: ____ / ____ / ______
Last                                              First                                                       mm       dd         yyyy

Facility/Agency:

__________________________________________________ Phone (____) _____ - _________