Workplan Example

Patient’s Name _________________________________________________________
(Last) (First) (M.I.) (ZIP CODE)

Street Address _____________________________________________________________________________________ _______________

REPORT OF VERIFIED CASE OF TUBERCULOSIS

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES-

REPORT OF VERIFIED CASE OF TUBERCULOSIS

FORM APPROVED OMB NO. 0920-0026 Exp. Date 05/31/2011

1. Date Reported
Month Day Year

3. Case Numbers State Case Number City/County Case Number

Year Reported (YYYY)

State Code

Locally Assigned Identification Number

2. Date Submitted
Month Day Year

Reason:

Linking State Case Number Linking State Case Number

4. Reporting Address for Case Counting City
Within City Limits (select one) Yes No

8. Date of Birth
Month Day Year

County

9. Sex at Birth (select one) 11. Race (select one or more) American Indian or Male Female Alaska Native 10. Ethnicity (select one) 6. Date Counted
Month Day Year

ZIP CODE 5. Count Status (select one) Countable TB Case Count as a TB case Noncountable TB Case Verified Case: Counted by another U.S. area (e.g., county, state) Verified Case: TB treatment initiated in another country Specify______________________ Verified Case: Recurrent TB within 12 months after completion of therapy 7. Previous Diagnosis of TB Disease (select one) Yes No

Asian: Specify____________ Black or African American Native Hawaiian or Other Pacific Islander: Specify_________________ White

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: Specify_______________________________ 13. Month-Year Arrived in U.S. Month Year

If YES, enter year of previous TB disease diagnosis:

14. Pediatric TB Patients (2 months? (select one) Yes No Unknown

16. Site of TB Disease (select all that apply) Pulmonary Pleural Lymphatic: Cervical Lymphatic: Intrathoracic