ࡱ> #` Qhbjbjmm 4l' FFFZ8~ZI""""D'4x*,&I(I(I(I(I(I(I$KhMLI9F9j&@'99LI""I<<<9j8"8"&I<9&I<<rET.F" pew@c:jFG$I0I FzsN:xsNFsNFFh,r18<4>7,,,LILIE<j,,,I9999ZZZ^dZZZ^ZZZ Texas Department of State Health Services Targeted Tuberculin Testing Screening Form Name: Birth Date: SS #: Address: Race: Sex: City/State/Zip: Telephone: Contact Person: Telephone:  TB Symptom review:  FORMCHECKBOX  Fever  FORMCHECKBOX  Chills  FORMCHECKBOX  Cough  FORMCHECKBOX  Productive Cough  FORMCHECKBOX  Night Sweats  FORMCHECKBOX  Hemoptysis  FORMCHECKBOX  Weight Loss (e"10%)  FORMCHECKBOX  Enlarged cervical lymph nodes  FORMCHECKBOX  Other: (Persons with symptoms of TB need a complete evaluation with skin test, sputum x 3, chest x-ray, and medical evaluation)  Previous Testing/Treatment: Date and results of previous TB Test: History of treatment of TB infection or disease:  FORMCHECKBOX  No  FORMCHECKBOX  Yes If yes, dates of drug start/stop:  For the following persons who are at highest risk of developing active tuberculosis disease if they are infected, tuberculin skin tests are considered positive at 5mm of induration or larger:  FORMCHECKBOX  HIV-infected  FORMCHECKBOX  Fibrotic changes on x-ray consistent with prior TB  FORMCHECKBOX  Organ transplant recipients  FORMCHECKBOX  Close (recent) contact with infectious case*  FORMCHECKBOX  Persons who are immunosuppressed for other reasons (e.g., taking the equivalent of >15 mg/day of prednisone for 1 month or more, taking tumor necrosis factor alpha antagonists) *(Recent contacts less than 5 years of age need x-rays (PA & Lateral) with medical evaluation even if skin test negative)  For the following persons with other known high-risk medical conditions or population risks for recent infection, tuberculin skin tests are positive at 10mm of induration or larger: Other High-Risk Medical Conditions  FORMCHECKBOX  Diabetes Mellitus FORMCHECKBOX  Silicosis FORMCHECKBOX  Gastrectomy or jejunoileal bypass FORMCHECKBOX  Age less than 5 years FORMCHECKBOX  Weight 10% less than ideal body weight FORMCHECKBOX  Chronic renal failure or on hemodialysis FORMCHECKBOX  Leukemias/Lymphomas FORMCHECKBOX  Cancer of Head/Neck/Lung FORMCHECKBOX  Skin test conversion: increase of 10mm or more within 2 years Population Risks  FORMCHECKBOX  Injection drug user  FORMCHECKBOX  Infant, child, or adolescent exposed to an adult in high-risk category  FORMCHECKBOX  Resident or employee of high-risk congregate setting: Correctional  FORMCHECKBOX  Health Care  FORMCHECKBOX  Homeless shelter  FORMCHECKBOX   FORMCHECKBOX  Mycobacteriology lab worker  FORMCHECKBOX  Other, explain:  FORMCHECKBOX  Recent arrivals** (within 5 years) from countries where TB is common:  FORMCHECKBOX  Afghanistan FORMCHECKBOX  Bangladesh FORMCHECKBOX  Brazil FORMCHECKBOX  Bosnia FORMCHECKBOX  Cambodia FORMCHECKBOX  China FORMCHECKBOX  Colombia FORMCHECKBOX  DR Congo FORMCHECKBOX  El Salvador FORMCHECKBOX  Ethiopia FORMCHECKBOX  Guatemala FORMCHECKBOX  Haiti FORMCHECKBOX  Honduras FORMCHECKBOX  India FORMCHECKBOX  Indonesia FORMCHECKBOX  Iran FORMCHECKBOX  Iraq FORMCHECKBOX  Kenya FORMCHECKBOX  Korea FORMCHECKBOX  Laos FORMCHECKBOX  Liberia FORMCHECKBOX  Mexico FORMCHECKBOX  Mozambique FORMCHECKBOX  Myanmar FORMCHECKBOX  Nicaragua FORMCHECKBOX  Nigeria FORMCHECKBOX  Pakistan FORMCHECKBOX  Panama FORMCHECKBOX  Peru FORMCHECKBOX  Philippines FORMCHECKBOX  Russian Fed. FORMCHECKBOX  Somalia FORMCHECKBOX  South Africa FORMCHECKBOX  UR Tanzania FORMCHECKBOX  Thailand FORMCHECKBOX  Uganda FORMCHECKBOX  Viet Nam FORMCHECKBOX  Zimbabwe FORMCHECKBOX  Other countries in Africa FORMCHECKBOX  Other countries in Asia FORMCHECKBOX  Other countries in Latin America** Include permanent change of residence, military service, or significant amounts of travel  For persons at low risk for TB, for whom tuberculin testing is not generally indicated, tuberculin skin tests are positive at 15mm of induration or larger:  FORMCHECKBOX  No risk identified  FORMCHECKBOX  Testing not done  First Test/Date: Read: Reading: mm Manufacturer: Lot #: Second Test/Date: Read: Reading: mm Manufacturer: Lot #: First Chest X-ray/Date: Results: Second Chest X-ray/Date: Results: Health-Care Provider:  Interpreter: TB-207 Targeted Tuberculin Testing Screening Form Rev 12/07 Texas Department of State Health Services Targeted Tuberculin Testing Screening Form Instructions Indications for use: Complete this form for any client receiving or requesting a tuberculin skin test, such as contacts, persons targeted for screening, or walk-ins requesting a test. This form can be used as a screening tool to determine if testing is indicated and as a tool to document risk prior to testing. It can also be used to document a symptom review for a person with a history of TB infection or disease. Directions: Complete a General Consent Form (L-36). The demographics section is self-explanatory. Complete all screening sections of the form by checking ALL of the boxes applicable to the client. For example, a person may be a contact to a new case, from Mexico, and also have diabetes. It is important to note every risk factor. Be cautious about using the population risk, Other. An example of a justifiable Other would be a job site screening of a business which employees 75% or more foreign-born persons. Depending on work environment, the business could be considered a high-risk congregate setting in which non-foreign born employees could be considered at risk. Do not use Other as a catchall. You must explain the risk based on your knowledge of the targeted testing document referenced below. Record Maintenance: For contacts, the information must be transferred to a TB-340. If the client has a positive reaction to the Mantoux skin test, an individual record will need to be opened to document follow-up. A system for retention and maintenance of the remaining screening forms is a local agency decision. The system used should allow for easy access. Reference: The reference for this form is: Targeted Tuberculin Testing and Treatment of Latent Tuberculosis Infection, CDC, MMWR, Vol. 49, RR-6, June 9, 2000 and the CDC fact sheet Targeted Tuberculin Testing and Interpreting Tuberculin skin Test Results, April 2005 available at www.cdc.gov/tb. It is important that persons using this form be familiar with these documents. Reading these documents will clarify questions regarding who is at risk and why. 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J i  & > W X q 0Lf~4NOk<@ȟ4;P@P P@P@UnknownG: Times New Roman5Symbol3& : Arial5& zaTahomaSMonotype SortsSymbol?5 : Courier New;Wingdings"1hhrȊ&sf PY4Y4!h4d 2QHX?pF2Targeted Tuberculin Testingcelia robinsonDSHS    Telephone: Conta ct Person: Telephone: TB &lt;/p&gt;Internal Administrator@     T\htEktContentID64EktContentLanguageEktFolderId64EktEDescriptionEktContentTypeEktContentSubType EktCmsPath EktExpiryType EktDateCreated EktDateModified EktDisabledTaxCategory EktCmsSize EktInPermEktSearchable EktQuickLinkekttaxonomyenabled EktAddressEktFolderNameEktTaxCategory _ ne@ -ڄ@;5BPDownloadAsset.aspx?id=24328\Summary &lt;p&gt;Texas Department of State Health Services Targeted Tuberculin Testing Screening Form Name: Birth Date: SS #: Address: Race: Sex: City/State/Zip: Telephone: Conta ct Person: Telephone: TB &lt;/p&gt;T&lt;p&gt;Texas Department of State Health Services Targeted TubEktTaxCategoryerculin Testing Screening Form Name: Birth Date: SS #: Address: Race: Sex: City/State/Zip: Telephone: Conta ct Person: Telephone: TB &lt;/p&gt;eksep# \Health Topics Tags\E\EPI-1 Notifiable Conditions Reporting Form #eksep# Oh+'08   ,@K.@i@~RPm>@i`@YTB-207T&lt;p&gt;Texas Department of State Health Services Targeted Tuberculin Testing Screening Form Name: Birth Date: SS #: Address: Race: Sex: City/State/Zip: Telephone: Conta ct Person: Telephone: TB &lt;/p&gt;Internal AdministratorT&lt;p&gt;Texas Department of State Health Services Targeted Tuberculin Testing Screening Form Name: Birth Date: SS #: Address: Race: Sex: City/State/Zip:  !"#$%&'()*+,-./012345689:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\^_`abcdefghijklmnopqrstuvwxyz{|}~Root Entry Fw@Data 7K1Table]NWordDocument4lSummaryInformation(DocumentSummaryInformation8CompObjq  FMicrosoft Office Word Document MSWordDocWord.Document.89qRoot Entry FK!Data 7K1Table]NWordDocument4l%  !"#$D&'()*+,-./0123456789:;<=>?@ABCEFGHIJKLMSummaryInformation(hDocumentSummaryInformation8h CompObjq  FMicrosoft Office Word Document MSWordDocWord.Document.89q՜.+,D՜.+,x4  (4' Targeted Tuberculin Testing Title