Connecticut Department of Public Health

Tuberculosis (TB) Control Program • 410 Capitol Avenue, MS#11-TUB • Hartford, CT 06134
FAX: 860-730-8271 Phone: 860-509-7722
Tuberculosis Contact Investigation Worksheet
Case Name: ____________________ Interviewer Name: _______________________ Submission to TB Control Program
CT Case Number: ________________ Phone: ________________________________ Round 1 Date: ________________
Date of Birth: ___________________ Date of Interview: _______________________ Round 2 Date: ________________
Site of Disease: _________________ Symptom Onset Date: ________________

CONTACT 1 Name: ________________________Date last exposed: _____________Site of Exposure: ________________

Address: ______________________________________Phone: ________________ Date of Birth:___________________
Step 1 – Screening: Risk Factors:  > 5 years old  Immunocompromised  Symptomatic  Other risk factor
If any risk factor is identified, evaluation should include screening, chest x-ray and assessment for window prophylaxis.
Test 1: TST read date: _______________ IGRA test:  QuantiFERON (QFT)  T-Spot
(48-72 hours after plant) MM: ______________ Date drawn: ___________________
(≥5mm is positive for contacts, refer for CXR)  Negative  Indeterminant  Positive (refer for CXR)
Test 2: TST read date: _______________ IGRA test:  QuantiFERON (QFT)  T-Spot
(48-72 hours after plant) MM: ______________ Date drawn: ___________________
(≥5mm is positive for contacts, refer for CXR)  Negative  Indeterminant  Positive (refer for CXR)
Step 2 – Imaging: CXR/CT date: _____________________ Results:  Normal  Abnormal (collect 3 sputum)
Step 3 – Treatment:
 LTBI (if specimen collected, wait for final culture)  Window Prophylaxis  Active TB Disease
Date started: _____________________________ Date completed: _______________________________
Regimen:  INH_______mg  RIF________mg  RPT + INH__________mg  Other______________________
Provider name & address: _____________________________________________ Phone: ______________________
NOTES:

CONTACT 2 Name: ________________________Date last exposed: _____________Site of Exposure: ________________

Address: ______________________________________Phone: ________________ Date of Birth:___________________
Step 1 – Screening: Risk Factors:  > 5 years old  Immunocompromised  Symptomatic  Other risk factor
If any risk factor is identified, evaluation should include screening, chest x-ray and assessment for window prophylaxis.
Test 1: TST read date: _______________ IGRA test:  QuantiFERON (QFT)  T-Spot
(48-72 hours after plant) MM: ______________ Date drawn: ___________________
(≥5mm is positive for contacts, refer for CXR)  Negative  Indeterminant  Positive (refer for CXR)
Test 2: TST read date: _______________ IGRA test:  QuantiFERON (QFT)  T-Spot
(48-72 hours after plant) MM: ______________ Date drawn: ___________________
(≥5mm is positive for contacts, refer for CXR)  Negative  Indeterminant  Positive (refer for CXR)
Step 2 – Imaging: CXR/CT date: _____________________ Results:  Normal  Abnormal (collect 3 sputum)
Step 3 – Treatment:
 LTBI (if specimen collected, wait for final culture)  Window Prophylaxis  Active TB Disease
Date started: _____________________________ Date completed: _______________________________
Regimen:  INH_______mg  RIF________mg  RPT + INH__________mg  Other______________________
Provider name & address: _____________________________________________ Phone: ______________________
NOTES:

Rev. 8/4/2021 TB Contact Investigation Worksheet FAX: 860-730-8271 Page 1 of 2

 Connecticut Department of Public Health
Tuberculosis (TB) Control Program • 410 Capitol Avenue, MS#11-TUB • Hartford, CT 06134
FAX: 860-730-8271 Phone: 860-509-7722
Tuberculosis Contact Investigation Worksheet
CASE NAME: CT CASE NUMBER:

CONTACT 3 Name: ________________________Date last exposed: _____________Site of Exposure: ________________

Address: ______________________________________Phone: ________________ Date of Birth:___________________
Step 1 – Screening: Risk Factors:  > 5 years old  Immunocompromised  Symptomatic  Other risk factor
If any risk factor is identified, evaluation should include screening, chest x-ray and assessment for window prophylaxis.
Test 1: TST read date: _______________ IGRA test:  QuantiFERON (QFT)  T-Spot
(48-72 hours after plant) MM: ______________ Date drawn: ___________________
(≥5mm is positive for contacts, refer for CXR)  Negative  Indeterminant  Positive (refer for CXR)
Test 2: TST read date: _______________ IGRA test:  QuantiFERON (QFT)  T-Spot
(48-72 hours after plant) MM: ______________ Date drawn: ___________________
(≥5mm is positive for contacts, refer for CXR)  Negative  Indeterminant  Positive (refer for CXR)
Step 2 – Imaging: CXR/CT date: _____________________ Results:  Normal  Abnormal (collect 3 sputum)
Step 3 – Treatment:
 LTBI (if specimen collected, wait for final culture)  Window Prophylaxis  Active TB Disease
Date started: _____________________________ Date completed: _______________________________
Regimen:  INH_______mg  RIF________mg  RPT + INH__________mg  Other______________________
Provider name & address: _____________________________________________ Phone: ______________________
NOTES:

CONTACT 4 Name: ________________________Date last exposed: _____________Site of Exposure: ________________

Address: ______________________________________Phone: ________________ Date of Birth:___________________
Step 1 – Screening: Risk Factors:  > 5 years old  Immunocompromised  Symptomatic  Other risk factor
If any risk factor is identified, evaluation should include screening, chest x-ray and assessment for window prophylaxis.
Test 1: TST read date: _______________ IGRA test:  QuantiFERON (QFT)  T-Spot
(48-72 hours after plant) MM: ______________ Date drawn: ___________________
(≥5mm is positive for contacts, refer for CXR)  Negative  Indeterminant  Positive (refer for CXR)
Test 2: TST read date: _______________ IGRA test:  QuantiFERON (QFT)  T-Spot
(48-72 hours after plant) MM: ______________ Date drawn: ___________________
(≥5mm is positive for contacts, refer for CXR)  Negative  Indeterminant  Positive (refer for CXR)
Step 2 – Imaging: CXR/CT date: _____________________ Results:  Normal  Abnormal (collect 3 sputum)
Step 3 – Treatment:
 LTBI (if specimen collected, wait for final culture)  Window Prophylaxis  Active TB Disease
Date started: _____________________________ Date completed: _______________________________
Regimen:  INH_______mg  RIF________mg  RPT + INH__________mg  Other______________________
Provider name & address: _____________________________________________ Phone: ______________________
NOTES:

Rev. 8/4/2021 TB Contact Investigation Worksheet FAX: 860-730-8271 Page 2 of 2