1 Appendix A_Supplemental TB Screening Form

  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
Minor	Last name:			First name:
	DOB:	A#:					Gender:
Healthcare Provider or Health Dept.	Name:		Phone number:			Clinic/Practice:
	Street address:		City/Town:			State:		Date of evaluation:
Program	Program Name:				Program Staff Member Present During Exam with HCP

Medical Information

Test Type

Indicators

Results

PPD/Tuberculin skin test (TST):

<2 years of age

Date performed: ____ / ____ /

Date read:____ / ____ / ______

Result: ________ mm

Interpretation:

Positive

Negative

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

>2 years of age

Specimen collection date: ____ / ____ / _____

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:

>15 years of age <15 years and positive IGRA/TST

Date: ____ / ____ / _____

Findings:

Normal

Abnormal

TB Screening Outcome

Negative for TB condition; No further follow up needed

TB, Latent (LTBI)

Referred to Health Department/Specialist for active TB evaluation

If minor was referred to Health Department/Specialist for active TB evaluation, what was the final decision?

No work-up needed for active TB disease

Work-up needed to rule out active TB disease

If a work-up is needed to rule out active TB disease, what was the reason?

Symptoms

Physical exam findings

Abnormal imaging study

Exposure history

Initiation of LTBI treatment

Other, specify:

Bacteriological Results
Collection Date	Specimen Collected By (Role)	Specimen Type (e.g., Sputum)	Test Type (e.g., AFB smear)	Result

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The purpose of this information collection is to provide ORR with critical health information for unaccompanied children in the care of ORR. Public reporting burden for this collection of information is estimated to average 3 minutes per healthcare provider, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. This is a mandatory collection of information (6 U.S.C. §279: Exhibit 1, part A.2 of the Flores Settlement Agreement (Jenny Lisette Flores, et al., v. Janet Reno, Attorney General of the United States, et al., Case No. CV 85-4544-RJK [C.D. Cal. 1996]). An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information subject to the requirements of the Paperwork Reduction Act of 1995, unless it displays a currently valid OMB control number. The OMB # is 0970-0466 and the expiration date is XX/XX/XXXX. If you have any comments on this collection of information, please contact UACPolicy@acf.hhs.gov.