Fillable Latent Tuberculosis Infection (LTBI) Report Form (Vermont Department of Information and Innovation on behalf of Vermont Dept of Health)

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Latent Tuberculosis Infection (LTBI) Report Form (Vermont Department of Information and Innovation on behalf of Vermont Dept of Health)

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The Latent Tuberculosis Infection (LTBI) Report Form (Vermont Department of Information and Innovation on behalf of Vermont Dept of Health) form is 1 page long and contains:

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U.S.A. forms for Vermont Department of Information and Innovation on behalf of Vermont Dept of Health

BROWSE VERMONT DEPARTMENT OF INFORMATION AND INNOVATION ON BEHALF OF VERMONT DEPT OF HEALTH (VT) FORMS

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Ver. 1 April 2019
Latent Tuberculosis Infection (LTBI) Report Form
Fax or mail completed form.
Fax: (802) 951-4061
Mail: 108 Cherry St. Suite 304 Burlington, VT 05401
Direct que
stions t
o the Inf
ectious
Disease
Epidem
iology P
rogram
at (802
) 863-72
40.
Reporting Information
Date of report: __ __/__ __ /__ __
Name of person reporting: ________________________ Phone: (__ __ __) __ __ __ - __ __ __ __
Facility/Institution: ______________________________ Provider (if not reporter): ________________________
Street address: ____________________________________________
Town: ___________________________________________________ State: __ __ Zip: __ __ __ __ __
Patient Information
Last name: ___________________________ First name: ________________________ MI: ____
Street address: ________________________________________________ Town: ___________________________
State: __ __ Zip: __ __ __ __ __ Phone: (__ __ __) __ __ __ - __ __ __ __
Sex: □ Male □ Female □ No answer Date of birth: __ __/__ __ /__ __ __ __
Country of birth: _________________________ Is this person a contact to an active TB case?: □ Yes
□ No
Race (select all that apply)
□ American Indian or Alaska Native □ Asian □ Black or African American
□ White □ Native Hawaiian or other Pacific Islander □ Unknown
Ethnicity
□ Hispanic or Latino
□ Not Hispanic or Latino
□ Unknown
Diagnosis Information
Reason for TB Evaluation (select all that apply)
□ TB signs or symptoms □ Health care worker □ Immigrant or refugee
□ Homeless □ Resident of congregate setting □ Contact to active TB case
□ Testing for school □ Testing for employment □ Immunosuppression or immunosuppressive treatment
□ Other: ____________________________________
Interferon Gamma Release Assay (IGRA)
Date collected: __ __/__ __ /__ __ Test type: □ QFT □ T-SPOT □ Other
Result: □ Negative □ Positive □ Indeterminate □ Unknown □ Not done
Tuberculin Skin Test (TST)
Date placed: __ __/__ __ /__ __ Date read: __ __/__ __ /__ __ Millimeters of duration: _______
Interpretation: □ Negative □ Positive □ Unknown □ Not done
Chest x-ray Date: __ __/__ __ /__ __ Result: □ Normal □ Abnormal
Treatment Plan
VDH Use Only:
#___________
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Latent Tuberculosis Infection (LTBI) Report Form (Vermont Department of Information and Innovation on behalf of Vermont Dept of Health)

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Completed 13 August 2020

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