New Jersey Department of Health

TB FIELD REFERRAL	Type of Referral:

1 2 3 4 5 6 7 8	Assigned To:

Last Name	First Name	Nickname/AKA

Patient Status:

Case: Pulmonary Non-Pulmonary Inactive

Suspect Contact Reactor Alien
Address	Apt.#/Floor

Services Required
X-Ray Meds DOT MD
Telephone No.

Age/Date of Birth

Sex

Sputum TST (Initial/Repeat)
Other
Race

Height

Size/Build

Other

Additional Information/Remarks (i.e., job, school, recreation, hangouts, language spoken, etc.)

Medical Provider

Date Missed Appt.

Z Status

# Mo. on Meds

Last Known Bacteriology:
Date Collected:	Type Specimen:
Smear	Negative	Positive	Not Done
Culture	Negative	M. tb	Atypical	Not Done
Disposition:
Received Required Services Refused Died
Moved (Enter new address in Remarks) Unable to Locate
Reassigned to Another Worker
Other (Explain):
Initiated By:

Date Assigned:

Target Disposition Date:

Dispositioned By:

Date Dispositioned:

TB-4

AUG 12	* Numbers correspond to type of referral on Field Activity Report.

TB-4, TB Field Referral

TB-4, field referral, tuberculosis, TB,

ewhite

2007-04-16

NJDOH