Form 1 Contact Investigation Form Active and Suspect

OMB Control No: 0970-XXXX

Expiration date: XX/XX/XXXX

Contact Investigation Form: Active/Suspect TB

Unaccompanied Children’s Program

Office of Refugee Resettlement (ORR)

General Information

Child

Last name:

First name:

DOB:

A#:

Gender:

Healthcare Provider

Name:

MD / DO / PA / NP

Phone number:

Clinic or Practice:

Street address:

City or Town:

State:

Date evaluated:

Program

Name of program staff with child:

Program name:

Exposure Information

Date of last exposure to person with illness: ____ / ____ / ______

When did exposure occur?

• Prior to arrival at ORR program

• After arrival at ORR program

Describe exposure to person with illness (e.g., child spent 4 hours a day in class for 5 days):

This contact (check all that apply):

• is an infant (less than 1 year old)

• is pregnant

• has an immunocompromising condition (e.g., HIV, cancer, on immunosuppressive medication)

Interventions

Select No or Yes for each question below. If Yes, enter the information in the corresponding table.

PPD/Tuberculin skin test (TST):

• No

• Yes

Date applied	Date read	Result (mm)	Interpretation (Positive or Negative)

TB blood test (Interferon-Gamma Release Assay [IGRA]):

• No

• Yes

Date drawn	Test type (Quantiferon or T-Spot)	Result

Chest x-ray (CXR):

• No

• Yes

CXR date	Findings (Normal or Abnormal)

Medications given:

• No

• Yes

Name	Date started	Date discontinued	Dose	Directions	Psychotropic
					No	Yes
					No	Yes

Actions Taken and Outcome

Was discharge delayed?

• No

• Yes

Outcome of ORR contact investigation (Check one):

• Not screened; pre-existing LTBI

• Incomplete evaluation (one negative TST/ IGRA performed in ORR custody, but was discharged prior to the test at > 8 weeks)

• Cleared (negative TST/IGRA done at > 8 weeks from exposure while in ORR custody)

• Newly diagnosed LTBI (Complete Medical Complaint form)

• Suspect/Active TB (Complete Medical Complaint form)

Comments:

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THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) Public reporting burden for this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.