Skip directly to search Skip directly to A to Z list Skip directly to navigation Skip directly to site content Skip directly to page options
CDC Home
Share
Compartir

International Tuberculosis Notification Form

(PDF – 24K)

TO: Health Officer, Physician, or Tuberculosis Control Personnel of:

Country Province District City or Village
       

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:  
Date of Birth:  
Place of Birth:  
Sex:  

This patient informed us that he/ she was going to the following location:


Patient’s Address  
City or Village  
District, Province  
Country  
Telephone if available  
e-mail address if available  
Contact person at this location  


If you have any questions, contact the following person who treated this patient in the United States:

Name  
Address  
City, State, Zip Code  
Phone, Fax, Email  

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)

Date Test Result
     
     
     
     
     
     

Current Medications (generic name), Dose, Frequency, Route of Administration, Start Date

Drug Dose Frequency Route Start Date
         
         
         
         
         
         

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
         
         
         
         
         
         

Any Other Comments:

 

 
Contact Us:
  • Centers for Disease Control and Prevention
    Division of Tuberculosis Elimination (DTBE)
    1600 Clifton Rd., NE
    MS E10
    Atlanta, GA 30333
  • 800-CDC-INFO
    (800-232-4636)
    TTY: (888) 232-6348
  • Contact CDC–INFO
USA.gov: The U.S. Government's Official Web PortalDepartment of Health and Human Services
Centers for Disease Control and Prevention   1600 Clifton Rd. Atlanta, GA 30333, USA
800-CDC-INFO (800-232-4636) TTY: (888) 232-6348 - Contact CDC–INFO
A-Z Index
  1. A
  2. B
  3. C
  4. D
  5. E
  6. F
  7. G
  8. H
  9. I
  10. J
  11. K
  12. L
  13. M
  14. N
  15. O
  16. P
  17. Q
  18. R
  19. S
  20. T
  21. U
  22. V
  23. W
  24. X
  25. Y
  26. Z
  27. #