Get Maryland Latent Tuberculosis Infection (ltbi) Reporting Form

This guide provides a comprehensive overview of how to accurately fill out the Maryland Latent Tuberculosis Infection (LTBI) Reporting Form online. Follow the step-by-step instructions to ensure all necessary information is completed with clarity and precision.

Follow the steps to accurately complete the LTBI reporting form online.

1. Press the ‘Get Form’ button to access the LTBI Reporting Form and open it in your online editor.
2. Enter the provider's name in the designated field.
3. Complete the provider affiliation section with the relevant details.
4. Fill in the provider's telephone number.
5. Indicate the LTBI case status by checking the appropriate option: Confirmed, Suspected TB Infection, or Not a case.
6. If known, enter the LTBI case number in the provided space.
7. Select whether this is an Initial Report or Follow-up Report.
8. Provide the last name, first name, and middle initial of the patient.
9. Fill in the patient’s date of birth in MM/DD/YYYY format.
10. Select the patient's sex at birth by checking the appropriate box.
11. Enter the patient’s address including unit number, city, state, zip code, and country of birth.
12. If the country of birth is unknown, check the corresponding box.
13. Select the county of residence from the dropdown menu.
14. Specify the month and year the patient arrived in the U.S.
15. Indicate whether the patient was born in the U.S. by checking 'Yes' or 'No'.
16. Select all applicable races from the options provided.
17. Choose the appropriate ethnicity from the options, indicating if the patient is Hispanic or Latino.
18. Fill out the reporting information, including the name of the reporting agency and date of first LTBI evaluation.
19. Select the type of reporting agency and reason for LTBI testing, checking one option for each.
20. Check all relevant risk factors and HIV status at diagnosis.
21. Complete the testing and evaluation section, including collection dates and results for smear and culture.
22. Provide test dates for TST and IGRA, including interpretations for each.
23. Indicate the chest radiography results and the date it was performed.
24. Specify the final evaluation outcome, checking either latent TB infection/no TB or active TB.
25. Indicate whether the patient was offered LTBI treatment and if they started treatment.
26. If treatment was not started, record the reason in the designated field.
27. Complete the LTBI treatment regimen prescribed and document the start and end dates.
28. Provide reasons for stopping treatment and note any serious adverse events or reactions.
29. Review all information entered for accuracy.
30. Finally, save changes, download, print, or share the completed form as needed.

Complete the Maryland Latent Tuberculosis Infection Reporting Form online today to ensure timely and accurate reporting.