Introduction to the Forms Julie Tomaro, BSN Washington State Department of Health...
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Transcript of Introduction to the Forms Julie Tomaro, BSN Washington State Department of Health...
Introduction to the FormsJulie Tomaro, BSN
Washington State Department of Health
INTERJURISDICTIONAL TB NOTIFICATION (IJN) TRANSFER AND
FOLLOW-UP FORMS
IJN Forms Online
The forms can be found on the National TB Controller’s Website at
www.tbcontrollers.org/resources/interjurisdictional-transfers
IJN Transfer Form
--Within 7 DaysWithin 30 DaysFinalOther
Page One: Top
IJN Transfer Form
--AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelaware
--StateCountyOther
--Within 7 DaysWithin 30 DaysFinalOther – See right
Page One: Middle
IJN Transfer Form
--FM
--YesNoUnknown
--American IndianAlaskan NativeAsianBlack or African American
--United StatesSee Comments - Page 3___AbkhaziaAfghanistan
--HomeCellWork
--YesNo
Page One: Bottom
IJN Transfer Form
--PulmonaryExtrapulmonaryPulmonary and extrapulmonary
--Treatment started – See Section 5Needs treatment
--PositiveNegativeUnknownN/ANot done
--PositiveNegativeUnknownN/ANot done
--PansensitiveINH resistantRIF resistantEMB resistantPZA resistantMultidrug resistantOther – See attached results
--YesNoUnknown
Page Two: Section 1
IJN Transfer Form
--HighMedium/closeLow/other-than-close
--TSTQFT-GITT-SpotNeeds testingN/AOther
--NegativePositiveIndeterminantBorderlineNot done
--AttachedNot donePendingNeeds x-ray
--Treatment started – See Section 5Needs treatmentWindow prophylaxis started – See Section 5Needs window prophylaxisN/A
Page Two: Section 2
IJN Transfer Form
--A – Active pulmonaryB1 – Noninfectious pulmonaryB2 – Noninfectious extrapulmonaryB3 – TB infectionB4 – TB contact
--YesNo
Page Two: Section 3
--Results attachedNeeds testN/A
--Results attachedNeeds sputaN/A
--Treatment started – See Section 5Needs treatmentN/A
IJN Transfer FormPage Two: Section 4
--Treatment started – See Section 5Needs treatmentN/A
IJN Transfer Form
--Active/suspect TBTB infectionWindow prophylaxis
--IsoniazidRifampinPyrazinamideEthambutolStreptomycinRifabutinRifapentineEthionamideAmikacin
--Daily DOTDaily SAT5x weekly DOT5x weekly SAT3x weekly DOT3x weekly SAT2x weekly DOT2x weekly SAT1x weekly DOT1x weekly SATOther- See attached MAR
--YesNoUnknown
--YesNo
Page Three: Section 5
--Yes – See attached notesNoUnknown
IJN Follow-up Form
--7 Day30 DayFinalOther:
Active/ Suspect TBContact Class A/BTB Infection
First Quarter
IJN Follow-up FormSecond Quarter
--FM
--YesNoUnknown
--American IndianAlaskan NativeAsianBlack or African American
IJN Follow-up Form
--InitiatedCompletedNot DoneReferredN/A
--No Infection/DiseaseTB InfectionActive DiseasePendingUnknownN/A
--ContinuingStartedStoppedNot startedCompleteReferredN/A
Third Quarter
--States--AlabamaAlaska
--PansensitiveINH resistantRIF resistantEMB resistantPZA resistantMDROther – See commentsOther – See attached results
--QFTT-Spot
IJN Follow-up Form
--Completed TreatmentNot TB Infection/DiseaseNever LocatedLostDiedRefusedMovedOther – See right
--YesNo
Fourth Quarter
Wrap Up
NTCA/NTNC Interjurisdictional Transfers:http://www.tbcontrollers.org/resources/interjurisdictional-transfers/
Please submit any questions or comments about the form to [email protected]