Tuberculosis Surveillance Summary Record
Updated November 2022
Briggs Tuberculosis Surveillance Summary Record is used to record and track TB surveillance for residents and facility employees.
The form Includes a baseline assessment for increased risk of TB as well as:
| • | Prior testing history |
| • | Initial skin (Mantoux) or blood (IGRA) testing and results |
| • | Recording: |
| § X-rays | |
| § Previous TB treatment | |
| § Bacteriology | |
| § Reporting to Health Department | |
| § Chemotherapy for infection or disease Voluntary HIV testing | |
| • | Also includes fields to record skin and blood tests, x-ray screening, and bacteriology testing |
| • | Additional space provided to record supplementary clinical information and comments |
· Size: 8 1/2" x 11"
· Paper: White
· Print: 2-sides; Black Ink
· Hole Punch: 5-Holes Top & Side
· Packaging: 100 per pad