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San Francisco Department of Public Health
Grant Colfax
Director of Health
City and County of San Francisco
London N. Breed
Mayor
SFDPH │101 Grove Street, Room 308, San Francisco, CA 94102
May 1, 2019
Dear San Francisco City and County Civil Surgeon,
NOTE: This toolkit has been updated since October 9, 2018. Certain changes have been made to
highlight the following:
• A Civil Surgeon TB Referral Checklist has been created to be used as a coversheet for
when Civil Surgeons refer patients to the Tuberculosis Clinic.
• LTBI diagnosis should be reported to the SFDPH Tuberculosis Prevention and Control
Program; however, patients should not be referred to the Tuberculosis Clinic for LTBI
treatment. Rather, LTBI treatment should be offered by the civil surgeon or the patient
should be referred to their primary medical home.
• All highlighted fields of the Confidential Morbidity Report must be completed.
As of October 1, 2018, new 2018 Civil Surgeons TB Technical Instructions state that IGRA
i
testing
is required for all applicants screened for status adjustment to lawful permanent resident in the US
who are aged 2 years or older and are now required to report LTBI to the health department. A
chest X-ray is required for all applicants with a positive IGRA result, known human
immunodeficiency virus (HIV) infection, or signs / symptoms of TB disease. Civil surgeons should
not refer applicants to the health department for IGRA testing or chest X-ray; all IGRAs and chest x-
rays ordered by civil surgeons must be performed independently of a health department. Applicants
requiring an evaluation for active TB disease (abnormal chest X-ray or HIV infected) should
continue to be reported to TB Control. In addition, civil surgeons are now required to report LTBI to
the health department. A summary of reporting requirements are below.
Reporting requirements:
Category
Definition
Reporting requirements
Latent TB
infection (LTBI)
ii
• Positive IGRA
• Normal Chest X-
ray
• No known HIV
• No signs /
symptoms of
active TB disease
The applicant’s name, contact information,
IGRA results, chest X-ray, and treatment
results must be reported to the San Francisco
Department of Public Health (SFDPH)
Tuberculosis Prevention and Control Program
using the Confidential Morbidity Report:
https://www.sfcdcp.org/wp-
content/uploads/2018/01/Reportable-Diseases-
List-CMR-SFDPH-FINAL-07.17.2018.pdf
San Francisco Department of Public Health
Grant Colfax
Director of Health
City and County of San Francisco
London N. Breed
Mayor
SFDPH │101 Grove Street, Room 308, San Francisco, CA 94102
Fax to 415-206-4565.
Civil Surgeons should offer LTBI treatment or
refer the patients to primary care for LTBI
treatment.
All HIV-infected
applicants
History of HIV infection
If the applicant has known HIV infection, an IGRA
and a chest x-ray must be performed and they
must be referred to the health department of
jurisdiction for sputum testing (regardless of above
results).
The patient will be contacted to schedule an
appointment to come to the clinic once the
following is faxed:
• Civil Surgeon Checklist
• Confidential Morbidity Report
• Chest X-ray results
• IGRA results
Active TB disease
(Suspected or
confirmed)
• Abnormal Chest
X-ray (including
chest X-rays
• May or may not
have signs /
symptoms of
active TB disease
Any confirmed or suspected case of active TB
disease is required by law to be reported within
one business day to the TB Prevention and
Control Program by telephone at (415) 206-8524,
or by fax at (415) 206-4565. This will also act as a
referral and we will work with you to set up an
appointment.
iii
The patient will be contacted to schedule an
appointment to come to the clinic once the
following is faxed:
• Civil Surgeon Checklist
• Confidential Morbidity Report
• Chest X-ray results
• IGRA results
For applicants who are diagnosed with LTBI, the I-693 form can be completed and given to the
applicant. Civil surgeons must inform such applicants that their LTBI diagnosis has been reported
to the local health department and should refer the patient to their primary care provider to receive
treatment to prevent tuberculosis disease (although not required to complete the status adjustment
San Francisco Department of Public Health
Grant Colfax
Director of Health
City and County of San Francisco
London N. Breed
Mayor
SFDPH │101 Grove Street, Room 308, San Francisco, CA 94102
process).
For your convenience, we have developed a Toolkit for Civil Surgeons to include:
• Cover letter with reporting instructions and links
• Confidential Morbidity Report (CMR) with highlighted fields requiring completion for
reporting
• List of potential enrollment sites if your patient does not have a PCP or insurance
• An example of an educational brochure on LTBI that you can provide your patients
• Civil Surgeon TB Referral Checklist
Further information on LTBI treatment and patient education materials can be found on our website
at: https://www.sfcdcp.org/tb-control/
. Please contact the San Francisco Department of Public
Health Tuberculosis Prevention and Control Program for any additional questions on reporting, TB
testing, diagnosis, or treatment. If you are a civil surgeon that is interested in further training on
LTBI diagnosis and treatment, please contact us as we can work with you in providing on-site
training.
Sincerely,
Chris Keh, MD
Director, Tuberculosis Prevention and Control Program
Disease Prevention and Control, Population Health Division
San Francisco Department of Public Health
2460 22nd Street, Ward 94
San Francisco, CA 94110
p: (415) 206-8524, f: (415) 206-4565
i
Interferon gamma release assay (IGRA)- test that measures a component of cell-mediated immunity reactivity to M.
tuberculosis in fresh whole blood (e.g. QuantiFERON-TB Gold Plus and T-SPOT.TB).
ii
For more information on diagnosing latent TB infection versus active TB disease, please refer to CDC guidelines:
https://www.cdc.gov/tb/education/provider_edmaterials.htm
iii
Applicants that live outside of San Francisco should be reported to their county of residence. SFDPH can assist civil
surgeons with the appropriate TB control in other jurisdictions if needed.
REPORTABLE DISEASES AND CONDITIONS
City and County of San Francisco San Francisco Department of Public Health
Title 17, California Code of Regulations (CCR) §2500, §2593, §2641-2643 and §2800-2812.
Every health care provider, knowing of or in aendance on a case or suspected case of any of the diseases or condions listed below, must report to the local health ocer for
the jurisdicon where the paent resides. Where no health care provider is in aendance, any individual having knowledge of a person who is suspected to be suering from
one of the diseases or condions listed below may make such a report to the local health ocer for the jurisdicon where the paent resides.
§2500 (c) The Administrator of each health facility, clinic or other seng where more than one health care provider may know of a cas e, a suspected case or an outbreak
of disease within the facility shall establish and be responsible for administrave procedures to assure that reports are made to the local ocer.
COMMUNICABLE DISEASE CONTROL UNIT
PHONE: (415) 554-2830
FAX: (415) 554-2848 M-F 8AM to 5PM
For urgent reports after hours, call 415-554-2830,
and follow the instructions on the voicemail to
page the on-call MD.
HIV REPORTING
PHONE: (415) 437-6335
ANIMAL CARE & CONTROL
ANIMAL BITES (Mammals Only)
PHONE: (415) 554-9422 FAX: (415) 864-2866
ENVIRONMENTAL HEALTH SERVICES
FOR PESTICIDE
PHONE: (415) 252-3862 FAX: (415) 252-3818
STD REPORTING
PHONE: (415) 487-5530 FAX: (415) 431-4628
TUBERCULOSIS REPORTING
PHONE: (415) 206-8524 FAX: (415) 206-4565
DISEASE OR CONDITION / URGENCY REPORTING REQUIREMENTS
URGENCY REPORTING KEY
Report immediately by telephone Report within one working day of identification Report within seven calendar days by FAX, phone or mail
Amebiasis
Anaplasmosis
Animal bites (mammals only) to Animal Care
Anthrax*, human or animal
Babesiosis
Botulism* (Infant, Foodborne, Wound, Other)
Brucellosis, animal (except infections due to
Brucella canis)
Brucellosis*, human
Campylobacteriosis
Chancroid to STD
Chickenpox
(Varicella) (outbreaks, hospitalizations
and deaths)
Chikungunya Virus Infection
Chlamydia trachomatis infections to STD
Cholera
Ciguatera Fish Poisoning
Coccidioidomycosis
Creutzfeldt-Jakob Disease (CJD)
Cryptosporidiosis
Cyclosporiasis
Cysticercosis
Dengue Virus Infection
Diphtheria
Disorders Characterized by Lapses
of Consciousness
Domoic Acid Poisoning (Amnesic
Shellfish Poisoning)
Ehrlichiosis
Encephalitis, infectious (specify etiology)
Escherichia coli shiga toxin producing (STEC)
including E. coli O157
Flavivirus infection of undetermined species
Foodborne illness
(2 or more cases from different households)
Giardiasis
Gonococcal infections (Including disseminated) to STD
Haemophilus influenzae, invasive disease, all
sero-types (in persons less than five years of age.)
Hantavirus infections
Hemolytic Uremic Syndrome
Hepatitis A, acute infection
Hepatitis B (specify acute case or chronic)
Hepatitis C (specify acute case or chronic)
Hepatitis D (Delta) (specify acut
e case or chronic)
Hepatitis E, acute infection
Human Immunodefiency Virus (HIV), Acute infection
Human Immunodeficiency Virus (HIV) Infection,
stage 3 (AIDS) to HIV Reporting
Influenza,deaths in laboratory-confirmed cases for
age 0-64 years
Influenza, novel strains (human)
Legionellosis
Leprosy (Hansen Disease)
Leptospirosis
Listeriosis
Lyme Disease
Lymphogranuloma Venereum (LGV) to STD
Malaria
Measles (Rubeola)
Meningitis (specify etiology)
Meningococcal infections
Mumps
Novel Virus Infection with Pandemic Potential
Paralytic Shellfish Poisoning
Parkinson's Disease, Report w/in 90 days to California
Parkinson's Disease Registry (CPDR)
Pertussis (Whooping Cough)
Pesticide-related illness or injury (known or
suspect-
ed cases) to Environmental Health
Services
Plague*, human or animal
Poliovirus infection
Psittacosis
Q Fever
Rabies, human or animal
Relapsing Fever
Respiratory Syncytial Virus (only report death
in patient less than five years of age)
Rickettsial Diseases (non-Rocky Mountain
Spotted Fever), including Typhus and Typhus
-like Illnesses
Rocky Mountain Spotted Fever
Rubella (German Measles)
Rubella Congenital Syndrome
Salmonellosis (other than Typhoid Fever)
Scombroid Fish Poisoning
Shiga toxin (detected in feces)
Shigellosis
Smallpox* (Variola)
Streptococcal infections, outbreaks of any
type and individual cases in food handlers
and dairy workers only
Syphilis to STD Reporting
Taeniasis
Tetanus
Transmissable Spongiform Encephalopathies
(TSE)
Trichinosis
Tuberculosis to Tuberculosis
Tularemia, animal
Tularemia*, human
Typhoid Fever (cases and carriers)
Vibrio infections
Viral Hemorrhagic Fevers*, human or animal
(e.g. Crimean-Congo, Ebola, Lassa and Mar-
burg viruses)
West Nile Virus (WNV) Infection
Yellow Fever
Yersiniosis
Zika Virus Infection
ANY UNUSUAL DISEASES
NEW DISEASE OR SYNDROME
NOT PREVIOUSLY RECOGNIZED
OUTBREAKS OF ANY DISEASE
7
1
7
1
1
7
7
7
1
1
7
7
1
1
* Potential Bioterrorism Agents
7
7
7
7
1
7
1
7
7
7
7
1
7
7
1
7
1
1
7
7
WHOM TO REPORT TO
REPORT OUTBREAKS, DISEASES, AND CONDITIONS TO COMMUNICABLE DISEASE CONTROL UNIT UNLESS OTHERWISE INDICATED
1
1
7
7
1
7
7
7
7
7
7
7
7
7
7
7
7
7
7
7
7
7
7
7
1
1
1
1
1
1
7
1
1
1
1
1
7
7
71
7
7
7
1
1
1
7
7
1
1
1
7
7
1
1
1
7
1
7
1
7
1
1
July 2018
COMMUNICABLE DISEASE CONTROL UNIT
PHONE: (415) 554-2830
FAX: (415) 554-2848 M-F 8AM TO 5PM
For urgent reports after hours, call
415-554-2830,and follow the instructions
on the voicemail to page the on-call MD.
HIV REPORTING
PHONE: (415) 437-6335
ANIMAL CARE & CONTROL
ANIMAL BITES (Mammals Only)
PHONE: (415) 554-9422 FAX: (415) 864-2866
ENVIRONMENTAL HEALTH SERVICES
FOR PESTICIDE
PHONE: (415) 252-3862 FAX: (415) 252-3818
STD REPORTING
PHONE: (415) 487-5530 FAX: (415) 431-4628
TUBERCULOSIS REPORTING
PHONE: (415) 206-8524 FAX: (415) 206-4565
DISEASE OR CONDITION / URGENCY REPORTING REQUIREMENTS
Cancer, including benign and borderline brain tumors
(except (1) basal and squamous skin cancer unless occurring
on genitalia, and (2) carcinoma in-situ and CIN III of the cervix)
(Report w/in 30 days to California Cancer Registry )
Tuberculosis to Tuberculosis Reporting
Transmissible Spongiform Encephalopathies
(TSE)
1
1
7
--
--
to HIV Reporting
For updates go to https://www.cdph.ca.gov/Programs/CID/DCDC/Pages/Public-Health-Reporting.aspx
anti -HBc IgM
State of California—Health and Human Services Agency
Department of Public Health
CONFIDENTIAL MORBIDITY REPORT
NOTE:
For STD, Hepatitis, or TB, complete appropriate section below. Special reporting requirements and reportable diseases on back.
DISEASE BEING REPORTED: __________________________________________________________________________________
Social Security Number
Age
Address: Number, Street
Apt./Unit Number
City/Town
Gender (Please Check One)
Estimated Delivery Date
Month
Day
Year
Phone Number
Area Code
Primary Phone Number
Patient’s Occupation/Setting
❒
Other _________________________
DATE OF ONSET
Month Day Year
DATE DIAGNOSED
Month Day Year
City ZIP Code
DATE OF DEATH Telephone Number Fax
Month Day Year () ()
Submitted by Date Submitted
(Month/Day/Year)
SEXUALLY TRANSMITTED DISEASES (STD) Not
Syphilis Syphilis Test Results
RPR Titer:__________
VIRAL HEPATITIS
Pos Neg Pend Done
anti-HAV IgM
er: ________
Hep D (Delta)
anti-Delta
Other: ______________
Date Treatment Initiate
Suspected Exposure Type
Month Day Year
❒
Treated (Drugs, Dosage, Route):
_________________________
Blood
transfusion
Household
contact
_________________________
f
to:
Refered to:
_________________
Child care
Other: ________________________________
TUBERCULOSIS (TB) TB TREATMENT INFORMATION
Status
x TB Skin Test Bacteriology
Current Treatment
Month Day Year Month Day Year
I INH
EMB
RIF PZA
h
Other: ____________
Date Performed Date Specimen Collected Month Day Year
Infected, No Disease Pending Date Treatment
Results:______________ mm
Not Done Source _______________________________________ Initiated
Chest X-Ray Month Day Year
Will treat
Unable to contact patient
Refused treatment
Referred to: _____________________
REMARKS
–
Ethnicity ( one)
Hispanic/Latino
Non-Hispanic/Non-Latino
Race ( one)
African-American/Black
Asian/Pacific Islander ( one)
Japanese
Korean
Laotian
Samoan
Vietnamese
Asian-Indian
Cambodian
Chinese
Filipino
Guamanian
Hawaiian
Other_________
Native American/Alaskan Native
White
Other: __________________________
Unknown
VDRL
Hep B
HBsAg
FTA/M
Pos
❒
Ne
Neg
Acute
anti-HBc
Chronic
Other:_________________
of Sex Partners last 12 months
Hep C
anti -HCV
Acute
PCR-HCV
Chronic
Communicable Disease Control Unit
San Francisco Dept of Public Health
25 Van Ness Ave, Ste 500
San Francisco, CA 94102
Report all non-STD, non-TB, non-HIV to:
Phone: (415) 554-2830
Fax: (415) 554-2848
STD FAX: (415) 431-4628
TB FAX: (415) 206-4565
HIV Phone: (415) 437-6335
State
ZIP Code
Male
Female
Trans Male
Trans Female
Unknown
Area Code Secondary Phone Number
–
–
–
Years
First Name/Middle Name (or initial)
Patient's Last Name
Month Day
Year
DOB
Country of Birth
Genderqueer/Gender Non-Binary
Please check all that apply:
Patient’s Last Name
First Name / Middle Name (or initial)
Address: Number, Street
City / Town
Social Security Number
DOB
Apt./Unit Number
Phone Number
Age
MONTH DAY YEAR
State
Male
Female
Trans Male
Trans Female
Unknown
Food service
Other
Patient’s Occupation/Setting
Area Code Secondary Phone Number
Area Code Primary Phone Number
Pregnant?
Estimated Delivery Date:
Gender (Please Check One)
Reporting Health Care Provider
Medical Record Number
Reporting Health Care Facility 5HPDUNKHUHLI\RXDUHD&,9,/685*(21
Address
City
State
ZIP Code
Telephone Number
Fax
Submitted by
Latent (unknown duration)
Chlamydia
G
onorrhea
Treated (Drugs, Dosage, Route):
Syphilis Test Results
RPR
VD
RL
CS
F-VDRL
TP-
PA
EIA/CLIA
Titer:
Titer:
P
os
Date Submitted
Genderqueer/Gender Non-Binary
Not Listed (Specify):
ZIP Code Country of Birth
On PrEP for HIV prevention
Y
N
UNK
TUBERCULOSIS (TB)
Status
Active Disease
Site(s)
Pulmonary
Chest X-Ray
TB Testing
IGRA
PPD/TST
Date Performed
Results:
REMARKS
Date Specimen Collected
Accession number
Source:
Smear:
Pathology suggests TB
Other test(s)
___________________________________
Month
Month
Month
Day
Day
Day
Year
Year
Year
Year
Bacteriology/Pathology
NAAT/PCR
Positive
Negative
Treated in office
Unable to contact patient
Refused treatment
Referred to:
Given prescription
Month Day Year
Neurosyphilis
Ocular Syphilis Y N UNK
Other:
Report all non STD, non-TB, non-HIV to:
Communicable Disease Control Unit
San Francisco Dept of Public Health
25 Van Ness Ave, Suite 500
San Francisco, CA 94102
CD Phone: (415) 554-2830
CD Fax: (415) 554-2848
STD Fax: (415) 431-4628
TB Fax: (415) 206-4565
HIV Phone: (415) 437-6335
Gender(s) of Sex Partners last 12 months
Please check all that apply:
anti
-HBs
DD MM YY
Specimen Source
Urine
Y N
UNK
Day care
Health care
School
Correctional facility
P
os
Neg
P
os
Neg
Neg
Late latent > 1 year
Congenital
Late (tertiary)
LTBI
Suspected
Date Performed
Normal
Attach all results to CMR
Pos Neg
Pending
Culture
:
Pos Neg
Pending
Other needle
exposure
Sexual
contact
Unt
reated
LGV
Pharyngeal
Rectal
Urethral/Cervical
Vaginal
Other:
PM 110 (SF 7/18)
Hep
A
Male Female
Trans Male Trans Female
Unknown Genderqueer/Gender Non-Binary
(Suspect)
Confirmed
Cavitary
Abnormal/Noncavitary
Early latent <1year
Secondary
Primary (lesion present)
Y
N
UNK
Extra-Pulmonary
RIF resistance detected
RIF resistance NOT
detected
STD TREATMENT INFORMATION
As of 10/31/18
https://www.sfcdcp.org/tb-control/tuberculosis-information-for-medical-providers/new-civil-surgeons-
ltbi-testing-treatment-and-reporting-toolkit/
PCP Referral List
Agency & Contact
Details for PCP
San Francisco Health Network
Phone number: 415-682-1740
Accepting patients without health insurance? No.
However, we will help you to enroll in various health
insurance and payment programs. To learn more, please
call (628) 206-7800 to schedule an appointment with a
Certified Enrollment Worker.
Accepted health insurances: Medicare, Medicaid, Healthy
Workers, Healthy Kids, San Francisco Health Plan or
Healthy San Francisco
Eligibility criteria:
-Must be a resident of San Francisco
-To receive care in the Network, you must be enrolled in
one of the accepted insurance or financial programs.
UCSF
Phone number:
1-844-PCP-UCSF
Accepting patients without health insurance? Yes, only if
patient is paying out of pocket (self-pay). However, if
needed, there are payment plans offered by speaking
with a Financial Counselor. Please call (415) 353-1966
Accepted health insurances: UCSF Medical Center
contracts with many major health insurance companies
and accepts several Medicare and Medi-Cal plans. A list of
health insurance companies and Medicare and Medi-Cal
programs that provide coverage for our services is
available below.
Eligibility criteria : None
One Medical
Phone number: 415-523-6317
Accepting patients without health insurance? Yes , only if
patient is paying out of pocket (self-pay)
Accepted health insurances: Aetna, Anthe, Blue Cross,
Blue Shield, Chinese Community Health Plan, Cigna,
Health Net, Multiplan (PCHS), Oscar, United Health Care,
Medicare… NO MEDICAID
Eligibility criteria : Membership fee required to enroll
As of 10/31/18
https://www.sfcdcp.org/tb-control/tuberculosis-information-for-medical-providers/new-civil-surgeons-
ltbi-testing-treatment-and-reporting-toolkit/
Kaiser San Francisco
Phone number: 800-464-4000
Accepting patients without health insurance? Yes, at a
non-member rate.
Accepted health insurances: Kaiser does not directly bill
other insurance. Patient will be billed directly and must
follow up with their insurance company in regards to
payment.
Eligibility criteria : Must be a resident of a Kaiser Service
Area
Sutter Pacific Medical
Foundation
Phone number: 866-681-0739
Accepting patients without health insurance? Yes
Accepted health insurances:
https://www.sutterhealth.org/spmf/health-plan?
Eligibility criteria :
•Living on a combined family income at or below 400% of
the Federal Poverty Level.
•Proof of identification
Clinic By The Bay
Phone number: 415-405-0207
Accepting patients without health insurance? Yes, working
uninsured San Francisco residents
Accepted health insurances: None
Eligibility criteria : Must be employed
Downtown Medical
Phone number: 415-362-7177
Accepting patients without health insurance? ? Yes.
Payment is expected at time of service. We accept cash
and all major credit/debit cards.
Accepted health insurances: Medicare, most PPO plans -
UHC, Aetna, Cigna Blue Cross, Blue Shield, Health Net,
Tricare, and etc
Eligibility criteria : Must not be a recipient of
Medicaid/Medi-Cal or Covered California
What do I need to
know about
Tuberculosis
Infection?
How can I have TB?
I don't even feel sick.
If your doctor informs that you have
latent TB, it is important that you
take medication to stop the germs in
your body from growing and making
you very sick. Even though you may
not feel sick, taking medications now
will prevent you and your family
from getting sick from TB disease in
the future.
It is a lot easier to treat latent
TB infection than TB disease.
What are my
treatment options?
Rifampin daily x 4 months
Rifapentine + Isoniazid weekly x
12 doses
Isoniazid daily x 6-9 months
Talk to your doctor today about the
treatment options that are right for
you.
TUBERCULOSIS
W
W
h
h
a
a
t
t
i
i
s
s
T
T
u
u
b
b
e
e
r
r
c
c
u
u
l
l
o
o
s
s
i
i
s
s
(
(
T
T
B
B
)
)
?
?
TB is a contagious airborne disease that is
caused by a special bacterium (germ). The
germs are coughed or sneezed into the air by
someone who is sick with active TB. You can
only catch TB by breathing in this germ.
TB has two stages. You have the first stage—
latent or inactive infection:
You have dormant (sleeping) TB germs in
your body.
You are not sick, and you have no
symptoms.
You cannot give the germs to anyone else.
Some people go on to a second stage—active
TB disease. People with active TB disease:
Have many active TB germs in their bodies.
Are sick and may have symptoms like
cough, fever, and weight loss.
Need to see a doctor.
Can give TB germs to others.
TB bacteria can live in
your body without you
feeling sick. Protect your
loved ones and those
around you by getting
treated.
For more information on TB, call your
local health department at
Or visit the CDC Division of
Tuberculosis Elimination website at
http://www.cdc.gov/tb
LTBI – English
The most important thing you can do
is to take your TB medicine! Take
your TB medication as often as your
doctor says.
Keep your appointment with your
nurse or your doctor
Notify your doctor if you can’t
make an appointment or are
traveling
Tell the doctor or nurse if you are
pregnant or taking any other
medications or have any other
health problems
Take your pills at the same time
every day. Include it in a daily
routine
Return to the doctor or nurse every
month for a refill or as scheduled.
Never give your medicine to
anyone else
Avoid alcohol
What can I do to prevent
active tuberculosis?
Only your doctor can tell if you have
TB. First, you will be given either the
skin test or a blood test. A positive
skin or blood test means TB germs are
in your body—Latent TB Infection. If
you have a positive test, you will need
a chest x-ray to find out if the germs
have caused any damage in your
lungs—Active TB Disease. You may
be asked to cough up sputum (mucus)
from your lungs to check for TB
germs.
How do I know if I am
infected with TB germs?
Y
Y
o
o
u
u
a
a
r
r
e
e
n
n
o
o
t
t
c
c
o
o
n
n
t
t
a
a
g
g
i
i
o
o
u
u
s
s
.
.
People with latent tuberculosis
infection CANNOT spread the
disease to other people.
T
T
u
u
b
b
e
e
r
r
c
c
u
u
l
l
o
o
s
s
i
i
s
s
d
d
i
i
s
s
e
e
a
a
s
s
e
e
i
i
s
s
p
p
r
r
e
e
v
v
e
e
n
n
t
t
a
a
b
b
l
l
e
e
.
.
If you have been infected with the germs,
you are at a higher risk of becoming sick
with tuberculosis. This can happen right
away or up to many years later.
You can prevent TB by taking medicine.
It is safe and kills the tuberculosis germ.
Your doctor may prescribe other, similar
medicine.
CIVIL SURGEONS TB
REFERRAL CHECKLIST
Make sure all boxes have been ch
ecked off before referring to
San Francisco Department of Public
Health
(SFDPH) TB Clinic. Please include this cover sheet in your fax to TB Clinic (415) 206-4565.
PATIENTS WILL BE CALLED TO SCHEDULE
AN APPOINTMENT ONCE WE RECEIVE ALL
REQUIRED
DOCUMENTS
.
WALK-INS WILL NOT BE ACCEPTED.
REFERRAL REQUIREMENTS (ALL MUST APPLY)
☐
Patient resides
is in San Francisco County
☐
Patient has an Abnormal Chest X
-ray*
☐
Positive IGRA Test (QFT or TSPOT)
CMR FORM
☐
Completed
ALL the highlighted sections of the attached CMR form
CD OF X-RAY
☐
CD of X
-rays should be sent with patient
X-RAY REPORT
☐
X
-ray report is attached
TEST RESULTS
☐
TB test results are attached
☐
HIV status
, if known, is attached*
*Note: If patient is HIV Positive, they should be referred to the SFDPH/TB Clinic, regardless
of X-ray or IGRA Results.
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Completed 10 January 2021

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