1. Completing the TB Follow-up Worksheet Indiana State Department of Health February 2009

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 CDCs 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 immigrants/refugees [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/Rs 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/Rs 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 Page 1 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. Indiana State Department of Health

9. Domestic CXR Page 1 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. Indiana State Department of Health

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

11. U.S. Microscopy/Bacteriology NOTE: In case of more than three sputums, record results of additional test(s) in Comments 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). Page 1 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. NOTE: Ideally collect 3 sputums at least 8 hours apart with one collected first thing in AM Indiana State Department of Health

12. Review of Overseas Treatment Page 2 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 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 physicians signature is not required. Please write the Physicians name who did the evaluation. Indiana State Department of Health