Read 53161%20TB%20Contact%20Screening%20of%20Active%20Cases.pdf text version

TUBERCULOSIS CONTACT SCREENING OF ACTIVE CASES

NORTH DAKOTA DEPARTMENT OF HEALTH DIVISION OF DISEASE CONTROL

SFN #53161 (08-05)

A copy of this form should be faxed to 701.328.0355 (confidential number) on two separate occasions: 1. The first copy should be submitted following the first PPD. 2. The second copy should be submitted upon completion of screening process. A completed Tuberculin Test Registration card must be mailed for all clients who tested positive.

TB Program Manager North Dakota Dept. of Health - Division of Disease Control 2635 E. Main Ave., PO Box 5520 Bismarck, ND 58506-5520 Phone: 701.328.2378 or 1.800.472.2180

Case Name

OTHER THAN CLOSE CONTACT DATE OF BIRTH AND AGE

NAME AND RELATIONSHIP TO CASE 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14.

CLOSE CONTACT

DATE 1ST PPD

DATE READ

M M

DATE 2ND PPD

DATE READ

M M

DATE CXR

RESULTS

PREVIOUSLY TREATED

TREATMENT PRESCRIBED NOW

Comments:

Information

2 pages

Find more like this

Report File (DMCA)

Our content is added by our users. We aim to remove reported files within 1 working day. Please use this link to notify us:

Report this file as copyright or inappropriate

724235


You might also be interested in

BETA
NPN Aug 11.pub
2010 Diabetes Audit InstructionsDRAFT3
PENNSYLVANIA STATUTES