1 Appendix A

  OMB Control No: 0970-0466

Expiration date: XX/XX/XXXX

Supplemental Form: TB Screening Unaccompanied Children’s Program Office of Refugee Resettlement (ORR)
General Information (to be completed by program staff)
Child	Last name:			First name:
	DOB:	A#:					Gender:
Healthcare Provider or Health Dept.	Name:		Phone number:			Clinic/Practice:
	Street address:		City/Town:			State:		Date of visit:
Program	Name of program staff with child:				Program name:

Medical Information (to be completed by healthcare provider’s office or health department)

PPD/Tuberculin skin test (TST):

Date applied: ____ / ____ / ______

Date read:____ / ____ / ______

Result: ________ mm

Interpretation:

Positive

Negative

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

Date drawn: ____ / ____ / _____

Test Type:

QuantiFERON®-TB Gold In-Tube test (QFT-GIT)

T -SPOT®.TB test (T-Spot)

Result:

Positive

Negative

Borderline/Equivocal/Indeterminate

Chest x-ray:

Date: ____ / ____ / _____

Findings:

Normal

Abnormal

TB Screening Outcome

Negative for TB condition; No further follow up needed

LTBI

TB rule out (if checked, enter testing info below)

Bacteriologic Results
Collection Date	Specimen Type (e.g., Sputum)	Test Type (e.g., AFB smear)		Result
Special Requirements for Release
If the child had been AFB smear positive, list the dates of the 3 consecutive negative AFB smears:		#1:	#2:		#3:
If the TB culture was positive and the DST was MDR or XDR, list the dates of the 2 subsequent negative cultures:		#1:	#2:

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) Public reporting burden for this collection of information is estimated to average 3 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.

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