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International Tuberculosis Notification Form
TO: Health Officer, Physician, or Tuberculosis Control
Personnel of:
Country |
Province |
District |
City or Village |
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The individual named below has active tuberculosis and was treated in
the USA. He or she has not completed treatment. This form is to notify
you so that treatment can be completed.
Tuberculosis Patient’s Name: |
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Date of Birth: |
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Place of Birth: |
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Sex: |
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This patient informed us that he/ she was going to the following location:
Patient’s Address |
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City or Village |
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District, Province |
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Country |
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Telephone if available |
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Contact person at this location |
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If you have any questions, contact the following person who treated
this patient in the United States:
Name |
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Address |
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City, State, Zip Code |
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Phone, Fax, Email |
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Date of diagnosis of current illness: ________
This illness was a (check one):
[ ] New episode of TB[ ] Treated for TB in the past,
before the current episode
If previously treated, describe the patient's
prior history of tuberculosis and treatment.
Site(s) of disease:
[ ] Pulmonary
[ ] Extra-pulmonary (specify):
Initial and most recent laboratory and radiographic test results
microscopy, cultures, drug susceptibility test results, radiographs,
and other critical lab tests) (use additional pages as needed)
Current Medications (generic name), Dose, Frequency, Route of
Administration, Start Date
Drug |
Dose |
Frequency |
Route |
Start Date |
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Treatment Plan
Our treatment plan for this patient is
specified below. This may differ from TB treatment in your country.
Please insure this patient completes a full course of treatment.
Drug |
Dose |
Frequency |
Route |
Start Date |
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Any Other Comments:
Last Modified: 06/27/2008
Last Reviewed: 05/18/2008 Content Source: Division of Tuberculosis Elimination
National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention
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Division of Tuberculosis Elimination
Attn: Content Manager, DTBE Web site
Centers for Disease Control and Prevention
1600 Clifton Rd., NE Mailstop E-10
Atlanta, GA 30333
CDC-INFO at (1-800) 232-4636
TTY: 1 (888) 232-6348
E-mail: cdcinfo@cdc.gov
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