Form 1 Public Health Investigation Form: Active TB

OMB Control No: 0970-0509

Expiration date: XX/XX/XXXX

Public Health Investigation Form: Active TB Unaccompanied Children’s Program Office of Refugee Resettlement (ORR)

General Information

Minor

Last name:

First name:

DOB:

A#:

Gender:

Program

Program name:

Person completing form & date:

Exposure Information

Source of potential exposure (e.g., grantee staff member): ____________________________________________________________

Date of first potential exposure: ____ / ____ / ______

Date of last potential exposure: ____ / ____ / ______

Exposure details (e.g., minor was potentially exposed for 4 hours a day in class for 5 consecutive days):

Was minor screened for active TB signs/symptoms upon notification of exposure?

No

Yes, date: ____/____/______

If screened, did minor have active TB signs/symptoms?

No

Yes

If Yes, was minor evaluated by a healthcare provider?

No

Yes (Complete Health Assessment form)

Public Health Actions

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

PPD/Tuberculin skin test (TST):

No

Yes

Result

Reaction (mm)

Date Performed

Date Read

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

No

Yes

Test type (Quantiferon or T-Spot)

Result

Collection Date

Imaging study:

No

Yes

Imaging Study Type

Result (Normal or Abnormal)

Date Performed

Medications given:

No

Yes

Name

Date started

Date discontinued

Dose

Directions

Psychotropic?

Discharged with med?

Was minor quarantined?

No

Yes, quarantine start date: ____/____/______ , quarantine end date: ____/____/______

Was discharge delayed due to potential exposure?

No

Yes, estimated end date of delayed discharge: ____/____/______

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), reason (e.g., runaway, age-out): ___________________________________________________________________________

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

Newly diagnosed LTBI (Complete Health Assessment form)

Diagnosed with active TB disease (Complete Health Assessment form)

Comments:

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 5 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 0970-0509 and the expiration date is XX/XX/XXXX. If you have any comments on this collection of information, please contact UACPolicy@acf.hhs.gov.