PLEASE PRINT OR TYPE ALL INFORMATION!

NJDOH USE ONLY:	Date Counted:
Final Dx (Check one):	+ Sputum Smear	Neg. Sputum Smear/+ Sputum Culture
Pulm-Other-Cul	Pulm-Clinical	Extra-Pulm

New Jersey Department of Health

TB Program

PO Box 363, Trenton, NJ 08625-0363	RECORD OF CONTACT INTERVIEW

Initial Interim Final

No Contacts Identified Interview Not Done	TB-70 #

Date Reported

Name: Last	First	MI

Street Address

City

County

Zip Code

Date of Birth

Telephone Number

Name of Employer/School/Congregate Setting

Address

Telephone Number of Employer/School/Congregate Setting

Occupation

Date of Interview

Date of Reinterview

Infectious Period:

From:	To:	Reason for Interview

Case	Suspect	Child <5 Years Old
CONTACT INFORMATION	EXAMINATION RESULTS	Remarks
Last Name, First Name

Address/Telephone Number	Nature

of Contact

(Codes 1-8)	DOB

and/or

Age	Sex	For-eign

Born	Last

Exposure

Date	Date Done	Date Done	X-Ray

Date	Therapy

Date	Completed Rx Date or Incomplete Code A-G
Results	Results	Results	Meds (K-P)
M

F	Y

N

QFT-

QFT+

mm

QFT-

QFT+

mm

M

F	Y

N

QFT-

QFT+

mm

QFT-

QFT+

mm

M

F	Y

N

QFT-

QFT+

mm

QFT-

QFT+

mm

M

F	Y

N

QFT-

QFT+

mm

QFT-

QFT+

mm

Name and Title of Interviewer

Agency Name

Signature	Date Submitted

Agency Telephone Number

Reviewed by NJDOH (Initials and Date)
NATURE OF CONTACT: 1-Household 2-Worksite 3-School 4-Jail/Prison 5-Health Care Facility 6-Social 7-Shelter 8-Other

TB-41	MEDS: K-INH L-RIF M-INH or RIF Intermittent N-Special Regimen (MDR) O-Other LTBI Rx P-Rx for TB Case/Suspect

AUG 13	RX INCOMPLETE: A-Death B-Moved, Records Referred C-Active TB D-Adverse Effects E-Refused F-Lost G-Provider Decision	Page 1 of 2 Pages.

RECORD OF CONTACT INTERVIEW, Continued	TB-70 #

Name: Last	First	MI

County

CONTACT INFORMATION	EXAMINATION RESULTS	Remarks
Last Name, First Name

Address/Telephone Number	Nature

of Contact

(Codes 1-8)	DOB

and/or

Age	Sex	For-eign

Born	Last

Exposure

Date	Date Done	Date Done	X-Ray

Date	Therapy

Date	Completed Rx Date or Incomplete Code A-G
Results	Results	Results	Meds (K-P)
M

F	Y

N

QFT-

QFT+

mm

QFT-

QFT+

mm

M

F	Y

N

QFT-

QFT+

mm

QFT-

QFT+

mm

M

F	Y

N

QFT-

QFT+

mm

QFT-

QFT+

mm

M

F	Y

N

QFT-

QFT+

mm

QFT-

QFT+

mm

M

F	Y

N

QFT-

QFT+

mm

QFT-

QFT+

mm

M

F	Y

N

QFT-

QFT+

mm

QFT-

QFT+

mm

M

F	Y

N

QFT-

QFT+

mm

QFT-

QFT+

mm

M

F	Y

N

QFT-

QFT+

mm

QFT-

QFT+

mm

Nature of Contact: 1-Household 2-Worksite 3-School 4-Jail/Prison 5-Health Care Facility 6-Social 7-Shelter 8-Other

TB-41	Meds: K-INH L-RIF M-INH or RIF Intermittent N-Special Regimen (MDR) O-Other LTBI Rx P-Rx for TB Case/Suspect

AUG 13	RX INCOMPLETE: A-Death B-Moved, Records Referred C-Active TB D-Adverse Effects E-Refused F-Lost G-Provider Decision	Page 2 of 2 Pages.

TB-41, Record of Contact Interview

TB-41, Record of Contact Interview, tuberculosis, contact information, tb program, TB Services

EWhite

2004-12-29

NJDOH