Guidelines on the Prevention and Control of Tuberculosis in Ireland

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<strong>Guidelines</strong> on the Prevention and Control of Tuberculosis in Ireland 2010HSE/HPSCAppendix 3: Tuberculosis Notification FormNational Tuberculosis Notification FormTB Case Registration: Health AreaCountyCCAYear 2 0Sequence NumberFirst Name / InitialSurname / InitialAddressPhoneA. SOCIODEMOGRAPHIC DETAILS B. DIAGNOSTIC & CLINICAL DETAILS1. Sex: Male Female2. Date of Birth3. Age (years)4. Most recent occupation5. Current employment statusPaid employmentUnemployedRetiredStudentHousewife / husbandOtherIf OTHER, please specify:6. Current living statusHome (private / rented) InstitutionB&B / HotelHostelHomelessPrisonOther If OTHER, please specify:7. Country of BirthIrelandOtherIf OTHER, please specify country:8. Race or ethnic groupCaucasianTravellerBlackChineseIndian subcontinent OtherIf OTHER, please specify:9. Refugee / asylum seekerYes NoIf YES, date/year of entry into Ireland:10. Date of onset of symptoms11. Date diagnosed12. Date of notification13. Diagnosis (tick one only)If Extrapulmonary or P+E,please specify site(s)15. Histology:PulmonaryPositiveNot done16. Chest x-ray:Active TBNormalNegativeUnknownInactive / Old TBOtherExtrapulmonaryPulmonary + extrapulmonary (P+E)14. Direct sputum microscopy:(a) 1st specimenSpecimen date(b) 2nd specimenSpecimen dateZN posZN negZN not doneZN posZN negZN not done17. Culture ResultsCulture posCulture negCulture not done UnknownIf done, please specify culture site:18. IsolateM. TBM. BovisOtherUnknownIf OTHER, please specify:19. Drug sensitivities(S = sens, R= res, N = not done)(Please fill for each drug used)IsoniazidPyrazinamideOther (specify)20. This case was found byPresenting as caseImmigrant screeningOther (specify)21. Previous history of TBYes NoIf YES, please specify:(a) year of diagnosis(b) treated >1month?Yes No(c) cured?Yes No22. BCG GivenYes23. BCG ScarYes24. Risk FactorsYesNoNoNo25. Immune Code(see explanatory notes)RifampicinEthambutolContact tracingOther screeningUnknownUnknownUnknownUnknownUnknownUnknownIf YES, please specify:(e.g. immunosupression, C2H5xs, IVDU)C. OUTCOME DETAILS (**Please note that 26 (a), (b), (c) and (d) apply to SMEAR POSITIVE cases ONLY**)26. (a) At 2 mths:Direct Sputum microscopyZN posZN negZN not doneCulturePosNegNot doneIf ZN pos at 2 mths then go to (b), otherwise go to (d)(b) At 3 mths:Direct Sputum microscopyZN posZN negZN not doneCulturePosNegNot doneIf ZN pos at 3 mths then go to (c), otherwise go to (d)(c) At 5 mths:Direct Sputum microscopyZN posZN negZN not doneCulturePosNegNot donePlease now go to (d)(d) Rx end:Direct Sputum microscopyZN posZN negZN not doneCulturePosNegNot done27. Treatment OutcomeCompletedInterrupted (>2months)Lost to follow up DiedIf dead, date of deathIf dead, was TB the direct cause?YesNo28. Case Denotified? (i.e. was diagnosis changed?)Yes NoIf YES, please specify new diagnosis-159-
<strong>Guidelines</strong> on the Prevention and Control of Tuberculosis in Ireland 2010HSE/HPSC(D) CASE LOCATION DETAILSNational Tuberculosis Notification FormDED name / code:Hospital name:Chart Number:Work Address:School Address:(E) CONTACT TRACING DETAILSIs this case:Index case or Contact of another case (please tick 1)If contact of another case, please completeName of index case:Address ofindex case:REG ID of index case:Date of notification of index case:COMPLETING DOCTOR SIGNATURETick section(s) completed:Signature 1Date 1Section completed:ABCDESignature 2Date 2Section completed:ABCDESignature 3Date 3Section completed:ABCDESignature 4Date 4Section completed:ABCDESignature 5Date 5Section completed:ABCDESignature 6Date 6Section completed:ABCDEThank you for completing this form.Please forward completed forms to your local Department of Public Health-160-
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Guidelines on the Prevention and Control of Tuberculosis in Ireland

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