New Jersey Department of Health

Tuberculosis Program

P. O. Box 363

Trenton, NJ 08625-0363

QUARTERLY CHEST CLINIC ACTIVITY REPORT

(Submit no later than the 15th day after the end of the quarter)

Name of Clinic

Year of Report:

Days and Hours of Operation

Quarter Covered:

January-March

April-June

July-September

October-December
Scheduled Physician Hours

Number of Clinic Visits During the Reporting Period by Category of Patient	Category of Patient
Cases	Suspect	Contacts	Reactors	Others	Total

Prepared By

Telephone Number

Date

DEFINITIONS

Category of Patient

CASE is a patient whose diagnosis of active TB disease is confirmed by laboratory findings or clinically.

SUSPECT is a patient with suspected active TB disease pending confirmation by laboratory findings or clinically.

CONTACT is a patient that is under medical supervision due to exposure to a suspected or confirmed active TB disease.

REACTOR is a patient with a significant reaction to a Mantoux tuberculin skin test who is neither a contact nor has an abnormal chest x-ray resembling active TB disease. Report Class IV TB patients in this category.

OTHER is a patient who does not conform to any of the categories above.

TB-1

AUG 13

TB-1, Quarterly Chest Clinic ACtivity Report

TB-1, chest clinic, activity report, quarterly report, tuberculosis, TB Program

EWhite

2007-04-24

NJDOH