HomeMy WebLinkAboutC07-196 CDPHEDEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT
ROUTING NO. 08 FHA 00022
APPROVED TASK ORDER CONTRACT — WAIVER #154
This Task Order Contract is issued pursuant to Master Contract made on 01/23/2007, with routing number 08 FAA 00016
STATE: CONTRACTOR:
State of Colorado for the use & benefit of the Board of County Commissioners of Eagle
Department of Public Health and County
Environment 500 Broadway
Disease Control & Epidemiology Eagle, Colorado 81631
Tuberculosis Program
4300 Cherry Creek Drive South
Denver, Colorado 80246
TASK ORDER MADE DATE: CONTRACTOR ENTTTY TYPE:
04/27/2007 Colorado Political Subdivision
PO/SC ENCUMBRANCE NUMBER:
PO FHA EPI0800022
TERM:
This Task Order shall be effective upon
approval by the State Controller, or designee,
or on 07/01/2007, whichever is later. The
Task Order shall end on 06/30/2008.
PRICE STRUCTURE:
Cost Reimbursement
PROCUREMENT METHOD:
Exempt
BID/RFP/LIST PRICE AGREEMENT NUMBER:
Not Applicable
LAW SPECIFIED VENDOR STATUTE:
Not Applicable
CONTRACTOR FEIN OR SOCIAL SECURITY NUMBER:
846000762
BILLING STATEMENTS RECEIVED:
Monthly
STATUTORY AUTHORITY:
Not Applicable
CONTRACT PRICE. NOT TO EXCEED:
$4,000.00
FEDERAL FUNDING DOLLARS: $0.00
STATE FUNDING DOLLARS: $4,000.00
MAXIMUM AMOUNT AVAILABLE PER FISCAL YEAR:
FY 08: $4,000.00
"Plus portion of two Blanket encumbrances
based on the Diagnostic Services and the
Direct Observed Therapy (DOT) visits."
STATE REPRESENTATIVE: CONTRACTOR REPRESENTATIVE:
Pam Pergande Board of County Commissioners of Eagle
Department of Public Health and Environment County
Disease Control & Epidemiology 500 Broadway
A-3 Eagle, Colorado 81631
4300 Cherry Creek Drive South
Denver, CO 80246
SCOPE OF WORK:
The Contractor shall assist in supporting tuberculosis prevention and control activities in Eagle
County.
Page 1 of 4
F.XI IIBITS:
The following exhibits are hereby incorporated:
Exhibit A - Additional Provisions (and its attachments if any — e.g., A-1, A-2, etc.)
Exhibit B - Statement of Work and Budget (and its attachments if any — e.g., B-1, B-2, etc.)
Exhibit C - Limited Amendment Template for Task Orders
GENERAL PROVISIONS
The following clauses apply to this Task Order Contract. These general clauses may have been expanded upon or made
more specific in some instances in exhibits to this Task Order Contract. To the extent that other provisions of this Task
Order Contract provide more specificity than these general clauses, the more specific provision shall control.
This Task Order Contract is being entered into pursuant to the terms and conditions of the Master Contract
including, but not limited to, Exhibit One thereto. The total term of this Task Order Contract, including
any renewals or extensions, may not exceed five (5) years. The parties intend and agree that all work shall
be performed according to the standards, terms and conditions set forth in the Master Contract.
In accordance with section 24-30-202(1), C.R.S., as amended, this Task Order Contract is not valid until it
has been approved by the State Controller, or an authorized delegee thereof. The Contractor is not
authorized to, and shall not; commence performance under this Task Order Contract until this Task Order
Contract has been approved by the State Controller or delegee. The State shall have no financial obligation
to the Contractor whatsoever for any work or services or, any costs or expenses, incurred by the Contractor
prior to the effective date of this Task Order Contract. If the State Controller approves this Task Order
Contract on or before its proposed effective date, then the Contractor shall commence performance under
this Task Order Contract on the proposed effective date. If the State Controller approves this Task Order
Contract after its proposed effective date, then the Contractor shall only commence performance under this
Task Order Contract on that later date. The initial term of this Task Order Contract shall continue through
and including the date specified on page one of this Task Order Contract, unless sooner terminated by the
parties pursuant to the terms and conditions of this Task Order Contract and/or the Master Contract.
Contractor's commencement of performance under this Task Order Contract shall be deemed acceptance of
the terms and conditions of this Task Order Contract.
The Master Contract and its exhibits and/or attachments are incorporated herein by this reference and made
a part hereof as if fully set forth herein. Unless otherwise stated, all exhibits and/or attachments to this Task
Order Contract are incorporated herein and made a part of this Task Order Contract. Unless otherwise stated,
the terms of this Task Order Contract shall control over any conflicting terms in any of its exhibits. In the event
of conflicts or inconsistencies between the Master Contract and this Task Order Contract (including its exhibits
and/or attachments), or between this Task Order Contract and its exhibits and/or attachments, such conflicts or
inconsistencies shall be resolved by reference to the documents in the following order of priority: 1) the
Special Provisions of the Master Contract; 2) the Master Contract (other than the Special Provisions) and its
exhibits and attachments in the order specified in the Master Contract; 3) this Task Order Contract; 5) the
Page 2 of 4
Additional Provisions -_Exhibit A, and its attachments if included, to this Task Order Contract; 4) the
Scope/Statement of Work - Exhibit B, and its attachments if included, to this Task Order Contract; 6) other
exhibits/attachments to this Task Order Contract in their order of appearance.
The Contractor, in accordance with the terms and conditions of the Master Contract and this Task Order
Contract, shall perform and complete, in a timely and satisfactory manner, all work items described in the
Statement of Work and Budget, which are incorporated herein by this reference, made a part hereof and
attached hereto as "Exhibit B".
5. The State, with the concurrence of the Contractor, may, among other things, prospectively renew or extend
the term of this Task Order Contract, subject to the limitations set forth in the Master Contract, increase or
decrease the amount payable under this Task Order Contract, or add to, delete from, and/or modify this
Task Order Contract's Statement of Work through a "Limited Amendment for Task Orders" that is
substantially similar to the sample form Limited Amendment that is incorporated herein by this reference
and identified as Exhibit C. To be effective, this Limited Amendment must be signed by the State and the
Contractor, and be approved by the State Controller or an authorized delegate thereof. Upon proper
execution and approval, this Limited Amendment shall become a formal amendment to this Task Order
Contract. This contract is subject to such modifications as may be required by changes in Federal or State
law, or their implementing regulations. Any such required modification shall automatically be incorporated
into and be part of this Task Order Contract on the effective date of such change as if fully set forth herein.
6. The conditions, provisions, and terms of any RFP attached hereto, if applicable, establish the minimum
standards of performance that the Contractor must meet under this Task Order Contract. If the Contractor's
Proposal, if attached hereto, or any attachments or exhibits thereto, or the Scope/Statement of Work -
Exhibit B, establishes or creates standards of performance greater than those set forth in the RFP, then the
Contractor shall also meet those standards of performance under this Task Order Contract.
Page 3 of 4
IN WITNESS WHEREOF, the State has executed this Task Order Contract as of the day first above
written.
CONTRACTOR: STATE OF COLORADO:
Board of County Comrnissioners of Eagle BIL RITTER, JR. G VERNOR
County C
Legal Name of Contracting Entity
By
For Executive Director
84600076
Soc' Securi Number or FEIN
Signature of Authorized Officer
Print Name & Title of Authorized Officer
GOVERNMENTAL ENTITIES:
(An attestation and seal are required) ,
OCALZ
� � J
Attest (Seal) BY(-- -
(Town/City/County Clerk or Equivapo
OLoaP
Department of Public Health and Environment
Department Program Approval:
(Place government seal here)
ALL CONTRACTS MUST BE APPROVED BY THE STATE CONTROLLER
CRS 24-30-202 requires that the State Controller approve all state contracts. This contract is not valid until the State
Controller, or such assistant as he may delegate, has signed it. The contractor is not authorized to begin performance until
the contract is signed and dated below. If performance begins prior to the date below, the State of Colorado may not be
obligated to pay for the goods and/or services provided.
By.
Date
STATE CONTROLLER:
Leslie M. Shenefelt
Page 4 of 4
r�
EXHIBIT A
ADDITIONAL PROVISIONS
To Task Order Contract Dated 04/27/2007 - Contract Routing Number 08 FHA 00022
These provisions are to be read and interpreted in conjunction with the provisions of the
Task Order Contract specified above.
The State has determined that this contract does not constitute a Business Associate relationship under
HIPAA.
2. The State, in order: to carry out its lawful powers, duties, and responsibilities under Section, 25-4-501, 8
C.R.S., as amended; and, to effectively utilize legislative appropriations made and provided therefore, in
coordination with like powers, duties, and responsibilities of the Contractor, has determined that public
health services are desirable in EAGLE COUNTY, Colorado.
Pursuant to 25-4-501, 8 C.R.S., as amended, the General Assembly has declared that tuberculosis is an
infectious and communicable disease, that it endangers the population of this state, and that the treatment
and control of said disease is a state responsibility and further, pursuant to 254-511, 8 C.R.S., assistance
under section 25-4-501, shall be given to any applicant who is suffering from tuberculosis in any form
requiring treatment and is without sufficient means to obtain such treatment. The State, through the
Tuberculosis Program has a mandate to provide care coordination services for the residents of the State
of Colorado.
4. Pursuant to the Catalog of Federal Domestic Assistance (CFDA) number 93.116, the State has been
awarded funds by the Department of Health and Human Services, Centers for Disease Control (CDC) for
tuberculosis control. The State shall contract with the Contractor to assure that tuberculosis control
services are provided for the residents of the above-mentioned county.
The State has formulated a comprehensive State plan, with associated budgets, to disburse these funds
throughout the state of Colorado. Under this comprehensive State plan, the State shall allocate these funds
to qualified entities to provide certain purchased services to the citizens of the state of Colorado on behalf
of the State.
6. In consideration of those services satisfactorily and timely performed by the Contractor under this Task
Order the State shall cause to be paid to the Contractor a sum not to exceed FOUR THOUSAND
DOLLARS, ($4,000.00) for the initial term of this Task Order. Of the total financial obligation of the
State referenced above, $4,000.00 are identified as attributable to a funding source of the state of Colorado.
Payment pursuant to this Task Order shall be made as earned, in whole or in part, from available State
funds encumbered in an amount not to exceed THIRTY-TWO THOUSAND DOLLARS ($32,000.00)
Statewide for Tuberculosis Direct Observed Therapy for State Fiscal Year 2008. Of the total financial
obligation of the State referenced above, one hundred percent is derived from the State General Fund.
The liability of the State, at any time, for such payments shall be limited to the unencumbered remaining
balance of such funds. If there is a reduction in the total funds appropriated for the purposes of this
Contract, then the State, in its sole discretion, may proportionately reduce the funding for this Contract or
terminate this Contract in its entirety.
Payment pursuant to this Task Order shall be made as earned, in whole or in part, from available State
funds encumbered in an amount not to exceed FOUR THOUSAND NINE HUNDRED DOLLARS
($4,000.00) Statewide for Tuberculosis Diagnostic Services for State Fiscal Year 2008. Of the total
financial obligation of the State referenced above, one hundred percent is derived from the State General
Fund. The liability of the State, at any time, for such payments shall be limited to the unencumbered
remaining balance of such funds. If there is a reduction in the total funds appropriated for the purposes of
To be attached to CDPHE Page I of 2 Revised: 12/19/06
Task Order v 1.0 (11 /05) contract template
EXHIBIT A
this Contract, then the State, in its sole discretion, may proportionately reduce the funding for this Contract
or terminate this Contract in its entirety.
Description
Tuberculosis Control and Outreach
Diagnostic Services
Direct Observed Therapy
($12.50 per onsite visit)
($25.00 per field visit)
TOTAL
Funding Source
State
State
State
Amount
$4,000.00
As Administered
As Administered
$4,000.00
To receive compensation under this Task Order Contract, the Contractor shall submit a signed monthly
Invoice/Cost Reimbursement Statement in a format acceptable to the State. A sample Invoice/Cost
Reimbursement Statement is attached hereto as Attachment A-1 and incorporated herein by this reference.
An Invoice/Cost Reimbursement Statement must be submitted within Thirty (30) calendar days of the end
of the billing period for which services were rendered. Expenditures shall be in accordance with the
Statement of Work attached hereto as Exhibit B and incorporated herein. These items may include, but are
not limited to, the Contractor's salaries, fringe benefits, supplies, travel, operating, indirect costs which are
allowable, and other allocable expenses related to its performance under this Task Order Contract.
Invoice/Cost Reimbursement Statements shall: 1) reference this Task Order Contract by its contract routing
number, which number is located on page one of this Task Order Contract; 2) state the applicable
performance dates; 3) state the names of payees; 4) include a brief description of the services performed
during the relevant performance dates; 5) describe the incurred expenditures if reimbursement is allowed
and requested; and, 6) show the total requested payment. Payment during the initial, and any renewal or
extension, term of this Task Order Contract shall be conditioned upon affirmation by the State that all
services were rendered by the Contractor in accordance with the terms of this Task Order Contract.
Invoice/Cost Reimbursement Statements shall be sent to:
Barb Stone
Tuberculosis Program
Colorado Department of Public Health and Environment
DCEED A-3
4300 Cherry Creek Drive South
Denver, CO 80246
To be considered for payment, billings for payments pursuant to this Task Order Contract must be received
within a reasonable time after the period for which payment is requested, but in no event no later than
thirty (30) calendar days after the relevant performance period has passed. Final billings under this Task
Order Contract must be received by the State within a reasonable time after the expiration or termination of
this Task Order Contract; but in no event no later than thirty (30) calendar days from the effective
expiration or termination date of this Task Order Contract.
Unless otherwise provided for in this Task Order Contract, "Local Match", if any, shall be included on all
billing statements as required by the funding source.
The Contractor shall not use federal funds to satisfy federal cost sharing and matching requirements unless
approved in writing by the appropriate federal agency.
To be attached to CDPHE Page 2 of 2 Revised: 12/19/06
Task Order v 1.0 (11 /05) contract template
N
O �
w
ATTACHMENT #A-(
9
O
A
o9
�W
wC7
�C a O
w�
A
w Ems- a
w Z
H
ATTACHMENT #A-(
9
O
H
V
AW
a
o
0
b
o
a
�
A
ATTACHMENT #A-(
9
O
EXHIBIT B
STATEMENT OF WORK
To Task Order Contract Dated 04/27/2007 - Contract Routing Number 08 FHA 00022
These provisions are to be read and interpreted in conjunction with the provisions of the Task Order Contract specified above.
A. Funds provided under the Task Order are to assist in supporting tuberculosis (TB) prevention and control
activities as stated in Colorado Revised Statues (CRS) 25 -4 -501 -Part 5 Tuberculosis (et seq) and Rules and
Regulations Pertaining to Epidemic and Communicable Disease Control (6 -CCR -1009-1, Regulation 4).
Contractor shall provide or coordinate the following services for all individuals within its service area
according to the statutes and regulations listed above and according to CDPHE Tuberculosis Manual, but in
no event less than those duties required by statute and rules (listed above). Use of funds shall be prioritized
as follows: priority 1) finding all patients with active TB and ensuring completion of appropriate therapy,
priority 2) finding and evaluating contacts of TB patients and ensuring completion of appropriate therapy,
3) evaluation of newly arrived immigrants and refugees with Class B TB designation, and priority 4)
targeted testing of high-risk persons and ensuring completion of therapy for latent TB infection (LTBI). If
available, use patient's medical insurance as primary payment source. CDPHE will reimburse for
diagnostic and clinical services at current Medicaid rate unless prior approval has been given by the
CDPHE TB Program.
1. Suspected or confirmed active TB
a. The Contractor shall provide, or arrange for, chest x-rays and interpretations.
b. The Contractor shall collect, or arrange for the collection of, specimens for mycobacteriology
testing on all persons suspected of having TB. Assure appropriate testing is performed, e.g.,
smears for acid-fast bacilli, (using concentrated fluorescent method), isolation of
mycobacteria (using rapid methods), identification of Mycobacterium tuberculosis complex
(MTB) (using rapid methods), and susceptibility testing (isoniazid, rifampin, ethambutol, and
pyrazinamide) on isolates of MTB. Contractor should use the CDPHE Laboratory for testing.
The CDPHE Laboratory will, at no charge to the Contractor, supply specimen containers and
perform the above testing for the Contractor. The Contractor shall arrange for the
transportation of the specimens to the CDPHE Laboratory for testing.
c. The Contractor shall provide, or arrange for, the placement of patients who require isolation.
The Contractor shall contact CDPHE TB Program for assistance, if needed, and to request
reimbursement from CDPHE for those costs incurred by the Contractor in isolating a patient.
d. The Contractor shall provide, or arrange for, all other necessary laboratory testing and
medical evaluation services.
e. The Contractor shall order TB medications through the CDPHE TB Program.
f. The Contractor shall provide the CDPHE with the medical insurance information for those
patients who have medical insurance.
g. The Contract shall provide, or arrange for, the treatment of patients with suspected or
confirmed active TB, including directly observed therapy, and ensure adherence to treatment.
h. The Contractor shall provide, or arrange for, a HIV antibody test for all persons diagnosed
with TB disease, regardless of their age or the apparent absence of risk factors for HIV
infection. In accordance with section 25-4-1401, et sem, C.R.S., as amended, the Contractor
shall report all known HIV antibody test results to the CDPHE. The Contractor shall inform
those individuals whom refuse testing of the risks associated with HIV/TB co -infection.
To be attached to CDPHE Pagel of 5 Revised: 12/19/06
Task Order v1.0 (11/05) contract template
EXHIBIT B
i. At least monthly, the Contractor shall monitor and evaluate those persons with suspected or
confirmed active TB.
j. The Contractor shall provide culturally appropriate patient education and information
pertaining to TB treatment and/or follow-up plan. The Contractor shall provide services in
patient's language using medical interpretation resources such as AT&T language line as
needed.
k. All reports of suspected or confirmed active TB shall include: reason for initiating, patient
name, date of birth, country of birth, date arrived in U.S., demographic information, locating
information, provider information, TB risk factors, results of diagnostic testing, results of
mycobacteriology including susceptibility results, dates of infectious period, treatment
information, changes in patients' status, diagnosis, or any other information as appropriate.
The Contractor shall report to CDPHE when a TB patient completes treatment, moves, or
transfers out of the Contractor's service area. Information may be reported via web -based TB
case/contact management system (TBdb) or via "Tuberculosis Surveillance and Case
Management Report" (TB 17), which is incorporated herein by this reference, made a part
hereof, and attached hereto as "Attachment B-1". Confirmed cases of TB shall include all
data elements identified in the "Report of Verified Case of Tuberculosis (RVCT)", which is
incorporated herein by this reference, made a part hereof, and attached hereto as "Attachment
B-2". The CDPHE shall provide the format and instructions for any additional information
requests. Report forms are subject to revision and Contractor agrees to use most recent
version.
2. Contacts to newly identified infectious TB (smear and/or culture positive pulmonanLor lar nngeal)
a. The Contractor shall ensure that all contacts to newly identified infectious TB cases are
identified, investigated, and receive appropriate evaluation. Contact investigation and any
follow-up needed as a result of an occupational exposure shall be conducted by the employer.
b. When indicated, the Contractor shall provide, or arrange for, chest x-rays and interpretations.
c. When indicated, the Contractor shall provide, or arrange for, other laboratory testing, and
other necessary medical evaluation services.
d. The Contractor shall provide, or arrange for, the treatment of patient (including directly
observed preventive therapy when appropriate), and ensure the completion of therapy for
infected contacts.
e. The Contractor shall order TB medications through the CDPHE TB Program.
f. The Contractor shall provide CDPHE with the medical insurance information for those
patients that have medical insurance.
g. The Contractor shall provide, or arrange for, an HIV antibody test to all persons with LTBI
with HIV risk factors or from an HIV endemic area. In accordance with section 25-4-1401, et
sem, C.R.S., as amended, the Contractor shall report all known HIV antibody test results to
the State. The Contractor shall inform all Individuals whom refuse testing of the risks
associated with HIV/TB co -infection.
h. At least monthly, the Contractor shall monitor and evaluate persons with LTBI during
treatment.
i. The Contractor shall provide culturally appropriate patient education and information
pertaining to LTBI treatment and/or follow-up plan. The Contractor shall provide services in
To be attached to CDPHE Page 2 of 5 Revised: 12/19/06
Task Order vL0 (11/05) contract template
EXHIBIT B
patient's language using medical interpretation resources such as AT&T language line as
needed.
j. The Contractor shall submit a preliminary Contact Investigation Report, (which is
incorporated herein by this reference, made a part hereof, and attached hereto as "Attachment
B-3" to the CDPHE TB Program after initiation of each contact investigation. The Contractor
shall submit a final report to CDPHE when a contact investigation is completed. Report.
forms are subject to revision and Contractor agrees to use most recent version.
k. For those persons identified, as part of a contact investigation, with latent TB infection, or
those with suspected latent TB infection requiring treatment recommendations from CDPHE,
the Contractor shall report reason for initiating, patient name, date of birth, country of birth,
date arrived in U.S., demographic information, locating information, provider information,
TB risk factors, results of diagnostic testing, treatment information, or any other information
as appropriate. The Contractor shall report to CDPHE when a patient completes treatment,
moves, or transfers out of the Contractor's service area. Information may be reported via
web -based TB case/contact management system (TBdb) or via "Tuberculosis Surveillance
and Case Management Report" (TB 17). The CDPHE shall provide format and instructions
for any additional information requests. Report forms are subject to revision and contractor
agrees to use most recent version.
3. Newly arrived immigrants and refugees with Class B TB designation
a. The CDPHE TB Program will notify the Contractor of all newly arrived Class B TB
immigrants/refugees via a CDC 75.17 form which is incorporated herein by this reference,
made a part hereof, attached hereto as "Attachment B-4" or Follow-up worksheet which is
incorporated herein by this reference, made a part hereof, attached hereto as "Attachment B-
5". Report forms are subject to revision and contractor agrees to use most recent version.
b.' Within thirty (30) calendar days of the Contractor's receipt of written notification from the
State of the arrival of a Class B immigrant/refugee, the Contractor shall contact that
immigrant and conduct, or arrange for, a TB screening that includes medical evaluation,
tuberculin skin test or whole blood interferon y assay, chest radiograph, and three spontaneous
sputum specimens for AFB smear and culture collected on consecutive days.
Upon completion of testing and examination, the Contractor shall fill out, sign, and date the
CDC 75.17 form or Follow-up worksheet, and return it within 90 days to:
Colorado Department of Public Health and Environment
Tuberculosis Program
Attn: Class B Coordinator
4300 Cherry Creek Drive South
Denver, CO 80246
d. The Contractor shall, when indicated, provide, or arrange for, treatment and ensure
completion of therapy.
e. The Contractor shall order TB medications through the CDPHE TB Program.
f The Contractor shall provide CDPHE with the medical insurance information for those
patients that have medical insurance.
g. The Contractor shall provide culturally appropriate patient education and information
pertaining to LTBI treatment and/or follow-up plan. The Contractor shall provide services in
patient's language using medical interpretation resources such as AT&T language line as
needed.
To be attached to CDPHE Page 3 of 5 Revised: 12/19/06
Task Order v1.0 (11 /05) contract template
EXHIBIT B
h. For those persons identified with LTBI or active TB, the Contractor shall report patient name,
date of birth, country of birth, date arrived in U.S., demographic information, locating
information, provider information, TB risk factors, results of diagnostic testing, treatment
information, or any other information as appropriate. Contractor will report when a patient
completes treatment, moves, or transfers out of the jurisdiction. Information may be reported
via web -based TB case/contact management system (TBdb) or via "Tuberculosis Surveillance
and Case Management Report" (TB 17). The State shall provide format and instructions for
any additional information requests. Report forms are subject to revision and Contractor
agrees to use most recent version.
4. Other high-risk persons with LTBI
a. When indicated, the Contractor shall provide, or arrange for, chest x-rays and interpretations.
b. When indicated, the Contractor shall provide, or arrange for, all other necessary laboratory
testing and medical evaluation services.
c. The Contractor shall provide, or arrange for, the treatment of patient and ensure the
completion of therapy.
d. The Contractor shall order TB medications through the CDPHE TB Program.
e. The Contractor shall provide the CDPHE with the medical insurance information for those
patients that have medical insurance.
f. The Contractor shall provide, or arrange for, a HIV antibody test to all persons with LTBI
with HIV risk factors or from an HIV endemic area. In accordance with section 25-4-1401, et
sem, C.R.S., as amended, the Contractor shall report all known HIV antibody test results to
the CDPHE. The Contractor shall inform those individuals whom refuse testing of the risks
associated with HIV/TB co -infection.
g. At least monthly, the Contractor shall monitor and evaluate persons with LTBI during
treatment.
h. The Contractor shall provide culturally appropriate patient education and information
pertaining to LTBI treatment and/or follow-up plan. The Contractor shall provide services in
patient's language using medical interpretation resources such as AT&T language line as
needed.
i. For persons with LTBI, the Contractor shall report reason for initiating, patient name, date of
birth, country of birth, date arrived in U.S., demographic information, locating information,
provider information, TB risk factors, results of diagnostic testing, treatment information, or
any other information as appropriate. Contractor shall report when a LTBI patient completes
treatment, moves, or transfers out of the jurisdiction. Information may be reported via web -
based TB case/contact management system (TBdb) or via "Tuberculosis Surveillance and
Case Management Report" (TB 17). The CDPHE shall provide format and instructions for
any additional information requests. Report forms are subject to revision and Contractor
agrees to use most recent version.
To be attached to CDPHE Page 4 of 5 Revised: 12/19/06
Task Order v 1.0 (11 /05) contract template
EXHIBIT B
j. Tuberculin skin testing, chest radiographs, chest radiograph interpretations, other diagnostic
testing, and medical evaluations are not eligible for reimbursement under this Task Order for
the following:
Correctional facility inmates;
ii. Persons, other than Class B TB immigrants/refugees, undergoing
immigration medical examinations;
iii. Paid or volunteer employees of health care facilities, long-term care
facilities, drug treatment centers, correctional facilities, shelters, schools, or
child care facilities who undergo skin testing as part of a routine
employment skin testing program.
5. TB education and consultation
As needed, the Contractor shall provide consultation services to providers in its service area
regarding TB reporting, screening, treatment, and follow-up.
6. Reports for contract monitoring
The Contractor shall provide the CDPHE with an annual report on TB activities in its service area.
A sample of the annual report is incorporated herein by this reference, made part hereof, and
attached hereto as "Attachment B-6". Report forms are subject to revision and contractor agrees
to use most recent version or submit a similar type of report. The Contractor shall submit report
within two months after funding period ends.
7. Confidentialitv
The Contractor shall maintain internal medical and administrative records in a manner which
ensures the confidentiality and security of those records in accordance with all applicable statutes
including, but not limited to, 25-1-107, C.R.S., as amended.
To be attached to CDPHE Page 5 of 5 Revised: 12/19/06
Task Order v 1.0 (11 /05) contract template
Last Name First Name MI
Current Home Address (Number & Street Name) Apt #
TUBERCULOSIS SURVEILLANCE AND CASE MANAGEMENT REPORT
�'%
Colorado Department of Public Health and Environment
Tuberculosis Program
4300 Cherry Creek Drive South
DCEED-TB-A3 ATTACHMENT B-1
Denver, Colorado 80246-1530
(303) 692-2638 phone (303) 691-7749 fax
Last Name First Name MI
Current Home Address (Number & Street Name) Apt #
Home Phone Number Other Phone Number Specify Type
Employer
Occupation: ❑ Health care worker ❑ Unknown ( )
❑ Corrections employee ❑ Other Work Phone Number
❑ Migrant farm worker
❑ Unemploved past 24 months Specifv other
Current U No TB exposure, not infected U TB, clinically active
Classification: ❑ TB exposure, no evidence of infection ❑ TB, not clinically active
Date Initiated Date Reported ❑ Latent TB infection, no disease ❑ TB suspect
Local Health Agency (LHA) PCP/Clinic Name
LHA Address (Number & Street Name)
LHA City LHA State LHA Zip Code
LHA Phone Number
❑
Mantoux- Aplisol
Gender:
❑
Male
Tine
❑
Date of Birth
❑
❑
Female
Symptomatic
❑
Administrative
❑
Targeted testing- individual
❑
Contact investigation
City State Zip Code
County
Race: 11American
Culture positive
Ethnicity:
❑
Not Hispanic/Latino
Employment
❑
Unknown
Indian/Alaskan
Known active
❑
Hispanic/Latino
Result
❑
Asian
Criteria: ❑
No risk factors for TB
❑
HIV Positive
❑
❑
Black/African
Country
❑
United States
Other Address (Number & Street Name)
Specify Type
❑
American
of Birth:
❑
Mexico
Mycobacteriological lab setting
❑
❑
Native
High-risk clinical conditions
❑
Other
❑
Child exposed to adult in high-risk
Hawaiian/Other
Specify other
Pacific Is.
Date
City State Zip Code
County
❑
White
Arrived in
US:
/
❑
Unknown
MonthNear
Home Phone Number Other Phone Number Specify Type
Employer
Occupation: ❑ Health care worker ❑ Unknown ( )
❑ Corrections employee ❑ Other Work Phone Number
❑ Migrant farm worker
❑ Unemploved past 24 months Specifv other
Current U No TB exposure, not infected U TB, clinically active
Classification: ❑ TB exposure, no evidence of infection ❑ TB, not clinically active
Date Initiated Date Reported ❑ Latent TB infection, no disease ❑ TB suspect
Local Health Agency (LHA) PCP/Clinic Name
LHA Address (Number & Street Name)
LHA City LHA State LHA Zip Code
LHA Phone Number
❑
Mantoux- Aplisol
❑
Mantoux- Unspecified
❑
Tine
❑
Not done
❑
Unknown
/ / Reading mm
Date Given
TST Result: ❑ Positive
Date Read ❑ Negative
❑ Unknown
Date last Reading mm
negative TST
PCP/Clinic Address (Number & Street Name)
PCP City PCP State PCP Zip Code
PCP Phone Number
Reason u
A/B notification- immigrant
U
Source case investigation
For Test: ❑
A/B notification- refugee
❑
Suspect case
❑
A/B notification- status change
❑
Symptomatic
❑
Administrative
❑
Targeted testing- individual
❑
Contact investigation
❑
Targeted testing- specific project
❑
Culture positive
❑
Transfer case/suspect
❑
Employment
❑
Unknown
❑
Known active
Result
Criteria: ❑
No risk factors for TB
❑
HIV Positive
❑
Recent arrival high prevalence cntry
❑
Recent contact to TB case
❑
Injection drug user
❑
Fibrotic changes on CXR
❑
Resident/employee high risk setting
consistent with old TB
❑
Mycobacteriological lab setting
❑
Immunosuppressed patients
❑
High-risk clinical conditions
❑
Other
❑
Child exposed to adult in high-risk
G:\TBFORMS\Original Forms\TB17 Form.xls revised 11/04
•
Pdhent Last Name First Name Ml Date of Birth
!_-\TRP0PhAC\nrinina1 Forms\TB17 Form.xls revised 11/04
X-RAY FINDINGS
ATTACHMENT -1
CXR Results:
❑ Cavitation ❑
Non -TB abnormality
Date Taken:
❑ Infiltrates ❑
Normal
❑ Pleural disease ❑
Other
HISTORYMEDICAL
Symptoms❑ None
Alcohol ❑ Yes
HIV ❑ Yes
& Length: ❑ Cough
Abuse: ❑ No
Test: ❑ No Allergies:
❑ Hemoptysis
❑ Unknown
❑ Unknown
❑ Chest pain
❑ Weight loss
Drug ❑ Injecting
HIV ❑ Positive Medications:
❑ Night sweats
Abuse: ❑ Noninjecting
Result: ❑ Negative
❑ Urinary
❑ No
❑ Not done
❑ Fever
❑ Unknown
❑ Unknown Weight:
❑ Other (specify)
/ !
HIV Test Date
RISKS AND SPECIAL
CONDITIONS
Exposure ❑ None
❑ Resident of long
Medical ❑ None ❑ Silicosis
Risks: ❑ Homeless
term care facility
Risks: ❑ Heart disease ❑ Immunosuppressive
❑ Resident of
(if Yes check one)
❑ Diabetes mellitus therapy
correctional facility
❑ Nursing home
❑ Weight loss > 10 lbs ❑ Cancer
(if Yes check one) ❑ Hospital
❑ Gastrectomy ❑ Hepatitis
❑ Federal prison
❑ Residential
❑ Jejunoileal bypass ❑ Renal failure
❑ State prison
❑ Mental health
❑ Local jail
❑ Alcohol/drug treatment
Special ❑ Pregnant EDC ! /
❑ Juvenile
❑ Other
Conditions: ❑ Postpartum breast feeding
❑ Other
❑ Unknown
❑ Other special conditions
❑ Unknown
❑ TST conversion in last 2 years
TREATMENT
❑ Current treatment
❑ Past treatment
Therapy Start Date
Therapy End Date
Treatment Isoniazid
mg Reason Therapy ❑ Died
Plan:
Rifampin
mg Stopped: ❑ Lost to follow-up
Pyrazinamide
mg ❑ Moved
Ethambutol
mg ❑ Adverse treatment event
Other
❑ Course completed
(Specify)
mg ❑ Uncooperative/refused
(Specify)
mg ❑ Unknown
❑ Other
CASE COMPLETION
• •R •
If the person is a contact to an active case
complete information on the source case
Final Case Status: ❑ Closed
❑
Moved away
❑
Lost contact
Last Name First Name
❑
Died
❑
Pending
Current Home Address (Number & Street Name)
If Moved New Address (Number & Street Name)
City State Zip Code
to f /
City State Zip Code
Relation to Source Exposure Dates
COMMENTS
Person co m a in orm
Date
!_-\TRP0PhAC\nrinina1 Forms\TB17 Form.xls revised 11/04
SPatient'$�Name:
• ILasO (Fuse IM
Street Address:
(Number, Street. City, Stale)
CDC
CENTERS FOR DISEASE CONTROL
AND PREVENTION
SOUN7E]
F1 F1
1. State Reporting:
Specify:
Alpha State Code ❑
R1 1llLnmur 9 n�
3. Data Submitted: By:
REPORT OF VERIFIED CASE
City
OF TUBERCULOSIS
of Tuberculosis:
Zip code)
23❑ Lymphatic: Other 6011 Meningeal
DEPARTMENT OF HEALTH d HUMAN SERVICES
1 L_-.� Yes
PUBLIC HEALTH SERVICE
121 • 71
CENTERS FOR DISEASE CONTROL
2� _� No
AND PREVENTION (CDC)
30❑ Bone and/or Joint 80E]Other'
ATLANTA, GEORGIA 30333
FORM APPROVED OM8 NO. 0920-0026 Exp. Oatrr 12/31/01
2.
Mo Day Yr.
State Case
Within, City Limits I ❑ Yes 2❑ No
❑ ❑ ❑
5. Month -Year Reported:
6. Month -Year Counted:
County
16. Additional Site of Disease:
'If site is
oo❑ Pulmonary
Number:
enter anatomic code
(see list)
io❑ Pleural
290 Lymphatic: Unknown 600 Meningeal
❑
If more than one previous
— episode, check here
2 1 ❑ Lymphatic: Cervical
30 ❑ Bone and/or Joint 70 ❑ Peritoneal
Mo. Yr.
❑ I ❑
City/County
Zip Code
check here
17. Sputum Smear:
18. Sputum Culture:
❑
—
❑❑❑
1 [�] Positive 3 ❑ Not Done
1 Positive 3 ❑ Not Done
Case Number:
7. Date of Birth:
8. Sex:
9. Race:
Mo. Day Yr.
I ❑ Male
1 [:]White 2 ❑ Black 3 ❑ American Indian or Alaskan Native
1I
❑ ❑ ❑❑7
2 ❑ Female
21. Chest X -Ray:
3. Data Submitted: By:
4. Address for Case Counting:
City
'If site is 'Other',
of Tuberculosis:
00❑ Pulmonary
23❑ Lymphatic: Other 6011 Meningeal
enter anatomic
code (see list)
1 L_-.� Yes
I o❑ Pleural
290 Lymphatic: Unknown 700 Peritoneal
❑
2� _� No
21❑ Lymphatic: Cervical
30❑ Bone and/or Joint 80E]Other'
220 Lymphatic: Intrathoracic
40❑ Genitourinary 9o❑ Site not Stated
Mo Day Yr.
If yes, list year of
19
Within, City Limits I ❑ Yes 2❑ No
❑ ❑ ❑
5. Month -Year Reported:
6. Month -Year Counted:
County
16. Additional Site of Disease:
'If site is
oo❑ Pulmonary
23❑ Lymphatic: Other 5o❑ Miliary
enter anatomic code
(see list)
io❑ Pleural
290 Lymphatic: Unknown 600 Meningeal
❑
If more than one previous
— episode, check here
2 1 ❑ Lymphatic: Cervical
30 ❑ Bone and/or Joint 70 ❑ Peritoneal
Mo. Yr.
❑ I ❑
Mo. Yr.
❑ =
Zip Code
check here
17. Sputum Smear:
18. Sputum Culture:
❑
—
❑❑❑
1 [�] Positive 3 ❑ Not Done
1 Positive 3 ❑ Not Done
1 ❑ Positive 3 ❑ Not Done If positive,
7. Date of Birth:
8. Sex:
9. Race:
Mo. Day Yr.
I ❑ Male
1 [:]White 2 ❑ Black 3 ❑ American Indian or Alaskan Native
1I
❑ ❑ ❑❑7
2 ❑ Female
21. Chest X -Ray:
a❑ Asian or Pacific Islander: Specify (Optional)
10. Ethnic Origin:
11. Country of Origin:
12. Month -Year Arrived in U.S.:
13. Status at Diagnosis of TB:
1 F] Hispanic
If U.S., check here ElMo.
Yr.
1 ❑Alive
z ❑ Not Hispanic
If not U.S., enter coin' ❑
try code (see list)
ID ❑❑
2 ❑ Dead
14. Previous Diagnosis
15. Major Site of Disease:
5o❑ Miliary
'If site is 'Other',
of Tuberculosis:
00❑ Pulmonary
23❑ Lymphatic: Other 6011 Meningeal
enter anatomic
code (see list)
1 L_-.� Yes
I o❑ Pleural
290 Lymphatic: Unknown 700 Peritoneal
❑
2� _� No
21❑ Lymphatic: Cervical
30❑ Bone and/or Joint 80E]Other'
220 Lymphatic: Intrathoracic
40❑ Genitourinary 9o❑ Site not Stated
If yes, list year of
19
'Other',
previous diagnosis
16. Additional Site of Disease:
'If site is
oo❑ Pulmonary
23❑ Lymphatic: Other 5o❑ Miliary
enter anatomic code
(see list)
io❑ Pleural
290 Lymphatic: Unknown 600 Meningeal
❑
If more than one previous
— episode, check here
2 1 ❑ Lymphatic: Cervical
30 ❑ Bone and/or Joint 70 ❑ Peritoneal
220 Lymphatic: Intrathoracic
It more than one
40❑ Genitourinary 80❑ Other- additional site, ❑ 88
check here
17. Sputum Smear:
18. Sputum Culture:
❑
19. Microscopic Exam of Tissue and Other Body Fluids:
❑
1 [�] Positive 3 ❑ Not Done
1 Positive 3 ❑ Not Done
1 ❑ Positive 3 ❑ Not Done If positive,
enter
2 E Negative 9❑ Unknown
2 Negative 9❑ Unknown
anatomic code(s)
2 1 Negative 90 Unknown (see list) ❑
20. Culture of Tissue and Other Body Fluids:
21. Chest X -Ray:
1 ❑ Positive 3 ❑ Not Done
If positive, enter
❑
I ❑ Normal 2 ❑ Abnormal 3 [:]Not Done
9 ❑ Unknown
z�� Negative s❑ Unknown
anatomic codes)
(see list)
❑
If Abnormal 1
e) ❑ Cavitary 2❑ Noncavitary
(check onConsistent
30 Noncavitary
Not Consistent
22, Tuberculin (Mantoux) Skin Test at Diagnosis:
i
1 L J Positive 3 ❑ Not Done
Millimeters (mm) of ❑
with TB
with TB
Unknown
211 Negative 9F] Unknown
If Abnormal 1 ❑ Stable 311 Improving
If Negative, was patient anergic? 1 F]Yes 21:1No 9F]Unknown
(check one)
21:1 Worsening 91:1 Unknown
Public reporting burden of this collection of information is estimated to average 30 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and
completing and reviewing the collection o1 information. An agency may not, conduct or spponsor, and a person is not required to respond to a collection of information unless it dtsplays a currently valid OMB control number. Send
comments regartlingg this burden estimate or any other aspect of this collect, of inform on, including suggestions for reducing this burden to CDC, Project Clearance Officer, 1600 Clifton Road, MS D-24, Atlanta, GA 30333, ATTN:
PRA (0920.0026). Do not send the completed form to this address.
Information contained on this form which would Germit identification of any individual has been collected with a guarantee that it will be hell in strict confidence, will be used only for surveillance purposes, and will not be disclosed
or released without the consent of the individual 'In accordance with Section 306(d) of the Public Health Service Act (42 U.S.C. 242m).
CDC 72.9A REV 12/98 1st Copy — State REPORT OF VERIFIED CASE OF TUBERCULOSIS Page 1 of 2
r REPORT OF VERIFIED CASE
OF TUBERCULOSIS
REPORT OF VERIFIED CASE OF TUBERCULOSIS
01
23. HIV Status: o❑ Negative 3❑ Refused 9❑ Unknown 24. Homeless Within Past Year:
1 ❑ Positive 4 ❑ Not Offered o ❑ No
2❑ Indeterminate 5 Test Done, Results Unknown 1 ❑ Yes
9 ❑ Unknown
If Positive, Based on: i ❑ Medical Documentation 2 ❑ Patient History goUnknown
if Positive, List: CDC AIDS Patient Number (If AIDS Reported before 1993)
State HIV/AIDS Patient Number (If AIDS Reported 1993 or Later)
City/County HIV/AIDS Patient Number (If AIDS Reported 1993 or Later)
25. Resident of Correctional Facility at Time of Diagnosis: o❑ No t ❑ Yes 90 Unknown
If Yes,
1 ❑Federal Prison 3❑ Local Jail 5❑ Other Correctional Facility
2❑ State Prison 40 Juvenile g❑ Unknown
Correctional Facility
26. Resident of Long -Term Care Facility at Time of Diagnosis: o No 1 ❑ Yes 90 Unknown
If Yes, 1 ❑ Nursing Home 4❑ Mental Health Residential Facility s❑ Other Long -Term Care Facility
2 E Hospital -Based Facility 5❑ Alcohol or Drug Treatment Facility 91:1 Unknown
3❑ Residential Facility
27. Initial Drug Regimen:
NO
YES
UNK.
NO
YES
UNK.
NO
YES
UNK.
Isoniazid
oU
t❑
g
Ethionamide
o❑•
1❑
g❑
Amikacin
o❑
1❑
-❑
Rifampin
01_1
1 E
9 E
Kanamycin
0
l
91:1
Rifabutine
o❑
t❑
9❑
Pyrazinamide
o❑
1❑
g
Cycloserine
o❑
1❑
9
Ciprofloxacin
o❑
t❑
- El
Ethambutoi
o❑
t❑
g 1
Capreomycin
0
t❑
g
Ofloxacin
0
1 1
g 1
Streptomycin
o❑
t❑
g 1
Para -Amino
0
1❑
g 1
Other
o❑
1❑
9❑
Salicylic Acid
28. Date Therapy Started:
29. Injecting Drug Use Within Past Year:
Mo. � ❑
o ❑ No i ❑ Yes 9
❑ Unknown
30. Non -Injecting Drug Use Within Past Year: 31. Excess Alcohol Use Within Past Year:
o ❑ No t ❑ Yes 9 ❑ Unknown o ❑ No i ❑ Yes 9 ❑ Unknown
32. Occupation (Check all that apply within the past 24 months):
1 ❑ Health Care Worker 3 ❑ Migratory Agricultural Worker 5 ❑ Not Employed within Past 24 Months
2❑ Correctional Employee 4❑ Other Occupation 91:1 Unknown
Comments:
...................... ................................ ............................................ .................. .................. ....................................... ................................................................ ............................................................... ................ ................................
CDC 72.9A REV 12/98 tat Copy — State REPORT OF VERIFIED CASE OF TUBERCULOSIS Page 2 of 2
fPatlent'Ti Name:
' (lasry
Street Address:
(Number, Street, City. State)
CDC 1
CENTERS FOR DISEASE CONTROL
AND PREVENTION
Initial Drug Susceptibility Report
SOUNDEX
❑❑❑❑
REPORT OF VERIFIED CASE
OF TUBERCULOSIS
DEPARTMENT OF HEALTH b HUMAN SERVICES
PUBLIC HEALTH SERVICE
CENTERS FOR DISEASE CONTROL
AND PREVENTION (CDC)
ATLANTA, GEORGIA 30333
FORM APPROVED OMB NO. 0820.0026 Exp. Det. 12/31/01
(Follow Up Report — 1)
State Reporting:
Year
Counted:
State Case
Number:
Enter Date First Isolate Collected
❑�❑
for Which Drug Susceptibility Was Done?
Specify:
34. Susceptibility Results:
Resistant
Susceptible
Not Done
Unknown
Isoniazid
Alpha State Code ❑
m
City/County
Case Number:
9
Rifampin
10
2
3❑
90
Pyrazinamide
1❑
2❑
3❑
9 E
Ethambutol
Submit this report for all culture -positive cases.
33. Initial Drug Susceptibility Results:
Was Drug Susceptibility Testing Done: 0❑ No 1 ❑ Yes 9 Unknown
If answer is No or Unknown, do not complete rest of report.
If Yes,
Enter Date First Isolate Collected
❑�❑
for Which Drug Susceptibility Was Done?
34. Susceptibility Results:
Resistant
Susceptible
Not Done
Unknown
Isoniazid
1❑
21:1
31:1
9
Rifampin
10
2
3❑
90
Pyrazinamide
1❑
2❑
3❑
9 E
Ethambutol
10
2
3❑
9 E
Streptomycin
1❑
2
30
9 E
Ethionamide
1 ❑
21:1
3❑
9❑
Kanamycin
1 E
2
3❑
9 E
Cycloserine
10
2❑
31-1
9 E
Capreomycin
1 ❑
2
3
9
Para -Amino
1❑
2❑
3❑
9
Salicylic Acid
Amikacin
1❑
2 F
3 E
9 E
Rifabutine
1❑
2❑
3 E
9❑
Ciprofloxacin
1 ❑
2❑
31:1
9 E
Ofloxacin
11:1
2 E
3
9 E
Other
10
2
3❑
9❑
Comments:
Public reporting burden of this collection of information is estimated to average 30 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed and
completing and reviewing the collection of information. An agency may not, conduct or sponsor, and a person is not required to respond to a collection of information unless it d2l s a currently valid OMB control number. tend
comments re rding this burden estimate or an other aspect of this collection of informatton, including suggestions for reducing this burden to CDC, Project Clearance Officer, 1600 C�fton Road, MS D-24, Atlanta, GA 30333, ATTN:
PRA (0920-0026). Do not send the completed lOrm to this address.
Information contained on this form which would permit identification of any individual has been collected with a guarantee that it will be hell in strict confidence, will be used only for surveillance purposes, and will not be disclosed
or released without the consent of the individual in accordance with Section 308(d) of the Public Health Service Act (42 U.S.C. 242m).
CDC 72.98 REV 12/98 tat Copy — State REPORT OF VERIFIED CASE OF TUBERCULOSIS Follow Up Report -1
w
r Patidnt's Name: REPORT OF VERIFIED CASE
a (bast) (First) (M, 1.) OF TUBERCULOSIS
Street Address: _ _
(Number, Street, City, Slate) Zip Code)
DEPARTMENT OF HEALTH 6 HUMAN SERVICES
FOR DISEASE CONTROL
CDC PUBLIC HEALTH SERVICE
• . , . • CENTERAND PREVENTION (CDC)
CENTERS FOR DISEASE CONTROL
ATLANTA, GEORGIA 30333
Arm PREVENTION FORM APPROVED OMB NO. 0920-0026 Exp. Data /2/31/01
Case Completion Report (Follow Up Report - 2)
SOUNDEX State Reporting: Year T1 I I I I I
❑ ❑ ❑ ❑ Counted: State Case
Specify: Number:
Case Numb
Alpha State Code m EDCase
Numb
er:
35. Sputum Culture
If Yes, Date Specimen Collected
If Yes, Date Specimen Collected on
Conversion Documented:
on Initial Positive Sputum Culture:
First Consistently Negative Culture:
Mo. Day Yr.
o❑ No 1❑ Yes 9❑ Unknown m m m
Mo. Day Yr.
m❑ m
36. Date Therapy Stopped:
37. Reason Therapy Stopped:
m mm
1 ❑ Completed Therapy 3 [:]Lost
5 ❑ Not TB 7 F]Other
z❑ Moved a❑ Uncooperative
or Refused s❑ Died s❑ Unknown
38. Type of Health Care Provider:
39. Directly Observed Therapy:
If Yes, Give Site(s) of Directly Observed Therapy:
1 ❑ Health Department
o❑ No, Totally Self -Administered
1 ❑ In Clinic or Other Facility
2❑ Private/Other
1 ❑ Yes, Totally Directly Observed
2❑ In the Field
3❑ Both Health Department
2❑ Yes, Both Directly Observed
3 E Both in Facility and in the Field
and Private/Other
and Self -Administered
9 ❑ Unknown
90 Unknown Weeks
Number of Weeks of Directly Observed Therapy: LLU
40. Final Drug Susceptibility Results:
If Yes, Enter Date Final Isolate
Was Follow-up Drug Susceptibility Testing Done? o No 1 ❑ Yes 9❑ Unk.
If answer is No or Unknown, do not complete rest
Collected for Which Drug Mo. Day Yr.
Susceptibility Was Done: m [11 m
of report.
41. Final Susceptibility Resistant
Susceptible NQ Done Unknown
Resistant Susceptible Not Done Unknown
Results:
Isoniazid 1❑
20 3 90
Capreomycin 1❑ 2❑ 3❑ g❑
Rifampin 1❑
2❑ 3❑ 91]Para-Amino
Salicylic Acid 1 2❑ 30 - El
Pyrazinamide 1
z❑ 30 9 E
Amikacin 1❑ 2❑ 30 9❑
Ethambutol 1❑
20 3❑ 9 E
Rifabutine 10 z❑ 30 - El
Streptomycin 1❑
z❑ 3 F 90
Ciprofloxacin 11:1 z❑ 3❑ 90
Ethionamide i❑
z❑ 3 90
Ofloxacin 1 z❑ 30 9❑
Kanamycin 1❑
2❑ 30 91:1
Other 1 z❑ 30 s❑
Cycloserine 1❑
z❑ 31-1 9❑
Comments:
r up., nn omuen m In. .."action or mwrmalwn is estimated to average 30 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data nestled and
completing an reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. fiend
comments regardingg This burden estimate or any other as of this collection of information, including suggestions for reducing this burden to CDC, Project Clearance Officer, 1600 ClAton Road, currently
Dd AB con, of umber. ATTN:
PRA (0920-0026). Do not send the completed form to this address.
Information contained on this form which would permit identification of any individual has been collected with a guarantee that it will be held in strict confidence, will be used only for surveillance purposes, and will not be disclosed
or released without the consent of the individual in accordance with Section 308(4) of the Public Health Service Act (42 U.S.C. 242m).
CDC 72.9C REV 12/96 1st Copy — State REPORT OF VERIFIED CASE OF TUBERCULOSIS Follow Up Report -2
cp
Q: a/
C o
U
O W
cZ
W
� o
l0 Q
L �
lti cn
W
V Z
V-
0
CL
N
AT
N
cII
C
LL
O
�
C
E
U)
U
O
a
U
E
=3
N
�
U
c
N
0)
co
0)
tfC
O
CL
N
O
N
E
m
t4
N 0 O
o
X CL n
C N 0
O U _N
E C
ro c)
Z fl
'ACNYENT # � '3
0
3
m
E
c
E
0
t
N
N
a UI
O
N
E
0
LL
mo
c �
N
00
E -o
N
>
orn �
AT
N
d o
E E
o
U
(� R
X
N_
>
0
O
5
Q
C
Q1
la
(n
0
J
N
ca
ai
X
N
N
t
U
p
E
E
N
w
d
�
m
7
�
N
Q
IL
_
f0
C
�
is
O
N
>
2
I
(j)
4- 2E
0 _
+�+ R O
o J X
W
------ Ub�0
a% t
4ZC
m
O
U
r- t
O U
C
T
O
U
v
C
V
`
U
U
U
U
>
N
>
N
>
c
t
t0
N
y
m
O
0)
O
CD
O
O
O C
aj
Q
c
o
aj
Q
C
o
aj
Q
C
o
6
pf
Q
C
o
ai
0)
Q
C C
0 a
E
m
N
E
CO
m
E
co
N
E
m
m
E
m
15 E
M
O
@
N
O
Z
M
O
5
N
O
FD
M
O
7�
Z
0
ml
Z
0
W,
Z
D
af,
Z
0
cf,
Z
0
w
'ACNYENT # � '3
0
3
m
E
c
E
0
t
N
N
a UI
O
N
E
0
LL
mo
c �
N
00
E -o
N
>
orn �
Anen iAl.cn#, Name, Address, Phone):
SEX: [ ] M [-N DATE OF BIRTH (Mo., Day, Yr.)
[ ] CLASSArculosis, clinically active. not infectious
( ] CLASS B-2 - Tuberculosis, not clinically active, not infectious
M
This space is provided for you to record the Local Health Department's report, if desired.
P
CDC 75.17 (Rev. 12/94)
Alien (Alien#, Name. Address, Phone):
SEX: I ) M I ) F DATE OF BIRTH (Mo.. Day. Yr.)
( ] CLASS B-1 - Tuberculosis. clinically active, not infectious
[ ] CLASS B-2 - Tuberculosis, not clinically active, not infectious
Your Initial Evaluation:
A. Direct Smear (in U.S.)
] Positive
( ) Negative
( ) Not Done
B. X-ray (in U.S.)
[ ] Normal
j Abnormal
f ) Not Done
ATTACHMENT B-4
NOTICE OF ARRIVAL OF ALIEN WITH TUBERCULOSIS
STATE HEALTH OFFICER:
Please Forward the Evaluation Copy and Acctimpanyiag Report
Of Medical Examination Performed Abroad (OF -157), to the
Appropriate Local Health Department.
Upon arrival in the United States this alien was requested to report
to the Local Health Department at his/her destination. X-ray taken abm
showed findings consistent with tuberculosis. The person may not have
received antituberculosis chemotherapy or chemoprophylaxis; therefore.
the Health Department may wish to initiate preventive treatment.
The Local Health Department is requested to submit a report of initial
evaluation by through you to:
Division of Quarantine. Data Mgr (E03)
Centers for Disease Control and Prevention (CDC)
Atlanta, Georgia 30333
'Htlimry will srn,l duan ro rAr Cmrrrr f Dirrrue Cmrrnl —4 Prernuia.
STATE HEALTH DEPARTMENT COPY
REPORT ON ALIEN WITH TUBERCULOSIS
LOCAL HEALTH OFFICER:
This person recently entered the United States and is referred to von beean9
the X-ray shows findings consistent with tuberculosis, as indicated in the
accompanying report of medical examination performed abroad. This person
may not have received chemotherapy or chemoprophylaxis and is referred to
You because you may wish to initiate preventative treatment. Your initial
evaluation wouldt"apNeciated. Please check the appropriate boxes below
and return this f to the State Health Officer..
If the alien does not report by please check here I ] and
forward this form to the StateJ.mini
Officer.` Retain for you records
the accompanying report of onperformed abroad(OF-157).
•Miliwry wln .rarul direr m rla C <asa Caned m y Prn•amnr
This forms is not intended to substitute for normal NOTE TO STATE HEALTH OFFICER: Upon receiving Division of Quarantine. Da gr (E03)
procedures for reporting tuberculosis to the state this completed copy from the Local Health Officer. Center for Disease Contr d Preveutiou (CDC
Health Department please forward to- Atlanta. Georgia 30333
CDC 75.17 (Rev. 12/94) CLASS B LOCAL HEALTH DEPARTMENT COPY
E. Has Patient Received Cbemotherapy/Propbylaxis iv the past?
C. X-ray (abroad)
D. Presumptive Diagnosis
( ] Yes I ) No I ) Unknown
(] Normal
[ ) Abnormal
( ) Pulmonary TB - Active
[ ] Pulmonary TB Not Active
F. Are you prescribing Chey/Propbylaxisl
j ) Not Done
- ( ) Yes I ) No
[ ] Pulmonary TB - Activity Undetermined Signature of Physician Date of Evaluation
( ) Unavailable
[ [ Extraplumonary TB
[ ) Non -TB Abnormality
( j No Abnormality
Name of Health Department
This forms is not intended to substitute for normal NOTE TO STATE HEALTH OFFICER: Upon receiving Division of Quarantine. Da gr (E03)
procedures for reporting tuberculosis to the state this completed copy from the Local Health Officer. Center for Disease Contr d Preveutiou (CDC
Health Department please forward to- Atlanta. Georgia 30333
CDC 75.17 (Rev. 12/94) CLASS B LOCAL HEALTH DEPARTMENT COPY
ATTACHMENT B-5
Burmese* Tuberculosis Follow-up Worksheet
A. Demographic
Al. Name (Last, First, Middle):
A2. Alien #:
A3. Visa Type:
A4. Initial U.S. Entry Date:
A5. Age:
A6. Gender:
A7. DOB:
A8. TB Class:
A9. Class Condition:
A10. Country of Examination:
A11. Country of Birth:
Al2. Portof Arrival:
A13. Port Contact Name:
A14. Port Contact Phone:
A15a. Sponsor Name:
A16a. Sponsor Agency Name:
A15b. Sponsor Phone:
A16b. Sponsor Agency Phone:
A15c. Sponsor Address:
A16c. Sponsor Agency Address:
B. Jurisdictional
61. Destination State:
B2. Jurisdiction: B3. Jurisdiction Phone #:
C. U.S. Evaluation
Cl. Date of Initial U.S. Medical Evaluation:
C2a. TST Placed:
❑Yes
❑No ❑Unknown
C2b. TST Placement Date:
C2c. TST mm:
C2d. TST Interpretation:
❑Positive
❑Negative ❑Unknown
C2e. History of Previous Positive TST:
❑
C3a. Quantiferon (QFT) Test:
❑Yes
[-]No ❑Unknown
C3b. QFT Collection Date:
C3c. QFT Result:
❑Positive
❑ative Ne
g []intermediate
❑Unknown
U.S. Review of Overseas CXR
Domestic CXR
Comparison
C4. Overseas CXR Available?
C7. U.S. CXR Done? ❑Yes []No
C11. U.S. CXR
Dyes []No ❑Not Verifiable
C8. Date of U.S. CXR:
Comparison to
C5. Interpretation of Overseas CXR:
C9. Interpretation of U.S. CXR:
Overseas CXR:
❑Normal ❑Abnormal ❑Poor Quality
❑Unknown
❑Normal ❑Abnormal ❑Unknown
❑Stable
C6. Overseas CXR Abnormal Findings:
C10. U.S. CXR Abnormal Findings:
❑Worsening
❑Abnormal, not TB ❑Cavity ❑Fibrosis
❑Abnormal, not TB ❑Cavity ❑Fibrosis
❑Improving
❑Infiltrate ❑Granuloma(ta) ❑Adenopathy
❑Infiltrate ❑Granuloma(ta) ❑Adenopathy
❑Unknown
❑Other (Specify)
[-]Other (Specify)
C12. U.S. Microscopy/ Bacteriology
❑ Sputa in U.S. Not Collected
Spec
Specimen
Date
AFB Smear Result
Culture Result
Drug Resistance
#
Source
❑Not Done
[]Positive
[]Not Done ❑NTM
[-]Not Done
❑Mono -RIF
1
❑Negative
❑Unknown
[-]Negative ❑Contaminated
❑Not DR
❑MDR -TB
❑MTB Complex []Unknown
❑Mono -INH
[]Other DR
[]Not Done
❑Positive
[-]Not Done ❑NTM
❑Not Done
❑Mono -RIF
2
[]Negative
❑Unknown
❑Negative ❑Contaminated
[]Not DR
[]MDR -TB
[]MTB Complex ❑Unknown
❑Mono -INH
❑Other DR
❑Not Done
❑Positive
❑Not Done ❑NTM
❑Not Done
❑Mono -RIF
3
❑Negative
❑Unknown
❑Negative ❑Contaminated
[:]Not DR
❑MDR -TB
❑MTB Complex ❑Unknown
❑Mono -INH
❑Other DR
Burmese Tuberculosis Follow-up Worksheet (continued) ATTACHMENT B-5
U.S. Review of Overseas Treatment
C13. Overseas Treatment
C14. Overseas Treatment Initiated:
C15. On Treatment on
C16. Completed
Recommended by Panel Physician:
❑Yes ❑No ❑Unknown
Arrival:
Treatment Overseas:
❑Yes
❑Yes
❑Yes
❑No
If Yes:
❑Patient -Reported
❑No
❑No
❑Unknown❑
Panel Physician -Documented
❑Unknown
❑Unknown
❑Both
C17. Overseas Treatment Concerns:
❑Yes ❑No
D. Disposition
D1. Disposition Date:
D2. Evaluation Disposition:
❑Completed Evaluation
❑Initiated Evaluation / Not Completed
❑Did Not Initiate Evaluation
❑Treatment Recommended
[—]Moved within U.S.
❑Not Located
❑No Treatment Recommended
[]Lost To Follow-up
❑Moved within U.S.
❑Returned to Country of Origin
❑Lost To Follow-up
[—]Refused Evaluation
❑Returned to Country
of Origin
❑Died
❑Refused Evaluation
❑Unknown
❑Died
❑Other, specify:
❑Unknown
❑Other, specify:
D3. Diagnosis.
❑Class 0 - No TB Exposure, Not Infected ❑Class 2 - TB Infection, No Disease ❑Class 4 - TB, Inactive Disease
❑Class 1 - TB Exposure, No Evidence of Infection ❑Class 3 - TB, Active Disease
D4. ❑RVCT Reported D5. RVCT #:
E. U.S. Treatment
E1. U.S. Treatment Initiated: E2. U.S. Treatment Start Date: E3. U.S. Treatment Completed: E4. U.S. Treatment End Date:
[—]No Treatment ❑Yes
❑Active Disease ❑No
❑LTBI ❑Unknown
❑Unknown
F. Comments
"Only for Burmese refugees arriving from Thailand
Last modified 12/20/2006
Tuberculosis
Semi -Annual Progress Report
Agency/Person
Date Submitted
ATTACHMENT B-6
Reporting Time Period _ July 1 - December 31 _ January 1 - June 30
Briefly describe TB activities and accomplishments during reporting period.
Describe any challengeslobstacles to providing TB services as specified in the
CDPHE TB contract during reporting time period.
STATE OF COLORADO
Bill Ritter, Jr., Governor
James B. Martin, Executive Director
Dedicated to protecting and improving the health and environment of the people of Colorado
4300 Cherry Creek Dr. S.
Denver, Colorado 80246-1530
Phone (303) 692-2000
TDD Line (303) 691-7700
Located in Glendale, Colorado
http://www.cdphe.state. co. us
August 16, 2007
Dear Contractor,
Laboratory Services Division
8100 Lowry Blvd.
Denver, Colorado 80230-6928
(303)692-3090
Colorado Department
of public Health
and Environment
Enclosed please find your fully approved contractual document with the Colorado Department of Public Health and
Environment, Disease Control and Environmental Epidemiology Division. Please keep these original documents for your
records.
If you have any questions or require further information, please feel free to contact me.
Sincerely,
rian Hanco
Fiscal Analy t
Disease Control and Environmental Epidemiology
Phone: (303) 692-2682
Fax: (303) 782-0904
E-mail : Brian.Hancockkstate.co.us
R
