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International Tuberculosis Notification Form
TO: Health Officer, Physician, or Tuberculosis Control Personnel of:
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.
This patient informed us that he/ she was going to the following location:
If you have any questions, contact the following person who treated
this patient in the United States:
Date of diagnosis of current illness: ________This illness was a (check one):[ ] New episode of TB If previously treated, describe the patient's prior history of tuberculosis and treatment.
Site(s) of disease:[ ] Pulmonary 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
Treatment PlanOur 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.
Any Other Comments:
Last Modified: 06/27/2008 Last Reviewed: 05/18/2008 |
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If you would like to order any of the DTBE publications please visit the online order form. You will need Adobe Acrobat™ Reader v5.0 or higher to read pages that are in PDF format. Download the Adobe Acrobat™ Reader. If you have difficulty accessing any material on the DTBE Web site because of a disability, please contact us in writing or via telephone and we will work with you to make the information available. Division of Tuberculosis Elimination
Centers for Disease Control & Prevention |