International Tuberculosis Notification Form

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

Health Officer Information 
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.

Patient Data 
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 Address and Phone Number 
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:

Contact Person in the US 
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)

Initial and Most Recent Test Results 
Date Test Result

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

Current Medications 
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.

Treatment Plan 
Drug Dose Frequency Route Start Date

Any Other Comments:

Page last reviewed: September 1, 2012
Content source: Division of Tuberculosis Elimination, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention