Get Latent Tb Infection Case Report Form - Mass.gov - Mass

This guide provides a step-by-step approach to completing the Latent TB Infection Case Report Form from the Massachusetts Department of Public Health. By following these instructions, users can ensure all necessary information is provided accurately and efficiently.

Follow the steps to fill out the form online effectively.

1. Press the ‘Get Form’ button to obtain the form and open it in your chosen format.
2. Begin filling out the patient’s last name, first name, phone number, address, and zip code. Ensure that all details are accurate and filled clearly.
3. Input the patient’s date of birth, gender, race, and ethnicity as self-reported. Double-check these entries for accuracy.
4. If applicable, check the Unique Address Condition box to indicate whether the patient is incarcerated or homeless.
5. Provide the country of birth for the patient and, if they are not from the U.S., include the date of entry into the country.
6. Record the date the Mantoux test (TST) was administered or the date of the IGRA lab test, ensuring proper format.
7. Indicate the interpretation of the results for the TST and IGRA tests based on the guidelines provided.
8. Check all applicable risk factors associated with the patient's exposure to tuberculosis, completing this section thoroughly.
9. Select the evaluation/treatment plan, ensuring to select the appropriate box based on the treatment options available.
10. Complete the reporting provider's name, the date the form is completed, the facility name, and the contact phone number.
11. Once all sections are filled out, review the form to ensure accuracy before choosing to save changes, download, print, or share the completed document.

Complete the Latent TB Infection Case Report Form online to contribute to public health efforts.