HomeMy WebLinkAbout20000147.tiff RESOLUTION
RE: APPROVE TASK ORDER FOR TUBERCULOSIS OUTREACH AND CONTROL
PROGRAM AND AUTHORIZE CHAIR TO SIGN
WHEREAS, the Board of County Commissioners of Weld County, Colorado, pursuant to
Colorado statute and the Weld County Home Rule Charter, is vested with the authority of
administering the affairs of Weld County, Colorado, and
WHEREAS, the Board has been presented with a Task Order for the Tuberculosis
Outreach and Control Program between the County of Weld, State of Colorado, by and through
the Board of County Commissioners of Weld County, on behalf of the Weld County Department
of Public Health and Environment, and the Colorado Department of Public Health and
Environment, commencing January 1, 2000, and ending June 30, 2000, with further terms and
conditions being as stated in said task order, and
WHEREAS, after review, the Board deems it advisable to approve said task order, a
copy of which is attached hereto and incorporated herein by reference.
NOW, THEREFORE, BE IT RESOLVED by the Board of County Commissioners of
Weld County, Colorado, that the Task Order for Tuberculosis Outreach and Control Program
between the County of Weld, State of Colorado, by and through the Board of County
Commissioners of Weld County, on behalf of the Weld County Department of Public Health and
Environment, and the Colorado Department of Public Health and Environment be, and hereby
is, approved.
BE IT FURTHER RESOLVED by the Board that the Chair be, and hereby is, authorized
to sign said task order.
The above and foregoing Resolution was, on motion duly made and seconded, adopted
by the following vote on the 19th day of January, A.D., 2000, nunc pro tunc January 1, 2000.
BOARD OF COUNTY COMMISSIONERS
.. W D COUNTY, COLD DO
ATTEST: Lv
•-
Barbara J. meyer, Chair
Weld County Clerk:to t� :? fge
'n<.4111917,
�p9� M. J. eile, Pro-Tem
Deputy Clerk to the B a, I I f EXCUSED DATE OF SIGNING (AYE)
e E. Baxter
APPROVED AS T,125 FORM: G� /f i
Dale K. Hall
iC
___,Gounty ney
Glenn Vaa ---
2000-0147
�" HL0027
\\C 44.4°41 _
ig
COLORADO
MEMORANDUM
TO: Barbara J. Kirkmeyer, Chair, Board of County Commissioners
FROM: Pat Persichino, Interim Director, Department of Public Health an ki 1"""
Environment
SUBJECT: TB Outreach and Control Task Order
DATE: January 17, 2000
Enclosed for Board review and approval is the TB Outreach and Control Task Order to become
part of the Master Contract between the Colorado Department of Public Health and Environment
(CDPHE) and Weld County.
Under the provisions of this task order, Weld County Department of Public Health and
Environment (WCDPHE) will provide active TB treatment, TB preventive treatment, provide for
and interpret chest x-rays and other medical evaluation services, conduct contact investigations
and TB skin test screening programs. WCDPHE will also follow-up with active patients to
ensure they receive appropriate information and education and they adhere to the completion of
their TB therapy.
For these services, the Health Department will receive an amount not to exceed $32,242 for the
period January 1, 2000 through June 30, 2000. This is $9,863 more than we were funded for the
same time period in 1999.
Health Department staff recommends your approval of this task order.
Enc.
2000.0147
Department or Agency Name
COLORADO DEPARTMENT OF PUBLIC
HEALTH AND ENVIRONMENT
Department or Agency Number
FHA
Contract Routing Number
00-00140
TASK ORDER
THIS TASK ORDER is made this 15th day of December, 1999, by and between: the State of Colorado, for the
use and benefit of th.e COLORADO DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT, whose
address or principal place of business is 4300 Cherry Creek Drive South,Denver,Colorado 80246 hereinafter
referred to as"the State"; and,the BOARD OF COUNTY COMMISSIONERS OF WELD COUNTY (a
political subdivision of the state of Colorado),whose address or principal place of business is 915 10th Street,
3rd Floor,Greeley. Colorado 80631, for the use and benefit of the Weld County Department of Public Health
and Environment, whose address or principal place of business is 1555 North 17th Avenue.Greeley,Colorado
80631,hereinafter referred to as "the Contractor".
WHEREAS, section 29-1-201, 8 C.R.S. as amended,encourages governments to make the most efficient and
effective use of their powers and responsibilities by cooperating and contracting with each other to the fullest extent
possible to provide any function, service,or facility lawfully authorized to each of the cooperating or contracting
entities,and to this end all State contracts with its political subdivisions are exempt from the State's personnel rules
and the State procurement code;
WHEREAS, the State has formulated a comprehensive State plan,with associated budgets, relative to the State's
programs and services which allocates funds to local health agencies in order to provide certain purchased services
to the people of Colorado;
WHEREAS, such funding is to be allocated through task order contracts with local health agencies;
WHEREAS,as to the State,authority exists in the Law and Funds have been budgeted,appropriated, and otherwise
made available, and a sufficient uncommitted balance thereof remains available for subsequent encumbering and
payment in Fund Number(s) 100,Organizational Unit Code(s)3640, 4645,4646 and 4648,Appropriation Code(s)
387 and 386, Program Code(s)9012, and Object Code(s) 5420 and 2710 under Master Contract Routing Number
00 FAA 00008 and Contract Encumbrance Number PO FHA EPI0000140 and Blanket Encumbrance Number PO
FHA EPI00000001;
WHEREAS,the State, in order: to carry out its lawful powers, duties,and responsibilities under Section
25-4-501,et seq., 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 Weld County,Colorado;
Page 1 of 7
WHEREAS,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;
WHEREAS,pursuant to 25-4-511, 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;
WHEREAS,The Centers for Disease Control and Prevention(CDC)has required that Human Immunodeficiency
Virus(HIV)serostatus shall be reported by the State for at least seventy five percent(75%) of all newly reported
Tuberculosis cases;
WHEREAS,pursuant to the Catalog of Federal Domestic Assistance(CFDA)Number 93.116,the State has been
awarded monies by the U.S. Department of Health and Human Services,Centers for Disease Control and Prevention
(CDC)for Tuberculosis control;
WHEREAS,the General Assembly of the State of Colorado has, for the fiscal year beginning July 1, 1999, passed
Senate Bill 99-215 (SFY99-00"Long Appropriations Bill") appropriating funding for Tuberculosis control;
WHEREAS,the State has encumbered funds under blanket encumbrance number PO FHA EPI00000001 for
Directly Observed Therapy(DOT)of Tuberculosis medications to ensure adherence to and completion of prescribed
regimens for effective disease control;
WHEREAS,the State and the Contractor agree that the most efficient and effective way of providing these services
is at the local level;
WHEREAS,all required approvals,clearances, and coordination have been accomplished from and with all
appropriate agencies.
NOW THEREFORE, in consideration of their mutual promises to each other, stated below,the parties hereto
agree as follows:
A. PERIOD OF PERFORMANCE AND CONTRACT TERMINATION. The effective date of this Task
Order is January 1,2000,or on the date this Task Order is approved by the State Controller,whichever is
later. The term of this Task Order shall commence on January 1,2000,and continue through and
including June 30,2000, unless sooner terminated by the parties pursuant to the terms and conditions of
the Master Contract.
Page 2 of 7
B. SCOPE OF WORK.
The Contractor shall provide or coordinate the following services, in order of priority listed
below, for all individuals within the service area according to the State TB Manual and Rules and
Regulations Pertaining to Epidemic and Communicable Disease Control effective 4/30/97:
a) Provide active TB treatment, including directly observed therapy as required by
Regulation 4 as referenced above;
b) Conduct contact investigations for newly diagnosed TB cases, including screening and
follow-up for contacts to TB;
c) Order TB Medications directly through the State Contract Pharmacy and administer TB
medication. Medications other than Isoniazid, Rifampin, Ethambutol, Pyazidimide, and
Pyridoxine require prior approval for reimbursement by the State;
d) Collect bacteriological specimens on all suspects and assure that sensitivities are
conducted on positive cultures for INH, Rifampin, Ethambutol, Streptomycin, and
Pyrazinamide;
e) Provide or arrange for chest x-rays and interpretation;
f) Provide or arrange for laboratory testing, and other necessary medical evaluation
services;
g) Periodically monitor and evaluate persons with active and suspected active TB, TB
infection and other persons as necessary to protect the public health:
h) Provide TB preventive treatment;
2. TB skin testing,chest x-rays and x-ray interpretations for the following are not eligible for
reimbursement under the terms of this contract:
• volunteers or employees of health care or long term care facilities
• volunteers, employees, or inmates of correctional facilities
• volunteers or employees of homeless shelters
• volunteers or employees of drug treatment centers
• volunteers or employees of schools or child care facilities
3. The Contractor shall recommend and offer an HIV antibody test to:
• all persons diagnosed with TB disease,regardless of age or apparent absence of risk
factors for HIV infection;
• all persons with positive TB skin tests(PPD)with HIV risk factors; and
• foreign-born persons from HIV endemic areas.
The Contractor shall report all known HIV antibody test results to the State pursuant to section 25-
4-1.401 et seq, C.R.S.. Individuals who refuse testing shall be educated regarding the risks
associated with HIV/TB co-infection.
Page 3 of 7
4. The Contractor shall supply the State, with complete patient data for all persons with infection and
disease for integration into the TB records system. Data will include:
a. TB infection cases(reactors)/Known TB Contacts--initial report of patient name, birth
date, demographic and other patient information,risk factors as identified on the
"Tuberculosis Surveillance and Case Management Report"(Attachment A),treatment
start date, drug regimen,and dosages. Follow-up report including length of treatment,
treatment completion date, and other case management/follow-up information via a
"Patient Follow-up Information and Transfer" form (TB-10 form--Attachment B).
b. Suspect/Known Active TB cases-- initial report of patient name, birth date, demographic
and other patient information, risk factors as identified on the"Report of Verified Case of
Tuberculosis" (RVCT form--see Attachment C), treatment start date, drug regimen,
dosages, how treatment was administered(e.g. direct observed therapy), number of doses
given, bacteriological results including drug sensitivity, changes in patients' status.
diagnosis,or any other information as appropriate. A TB-10 form will also be used by
the Contractor to report when a TB patient completes treatment, moves or transfers out of
the county. The State shall provide format and instructions for any additional data
transfer required.
5. The State shall immediately notify the Contractor of all newly arrived Class A or B TB
immigrants to the county via a CDC 75.17 form(copy attached and made part hereof as
Attachment D). The Contractor, in turn, will contact the immigrant and conduct TB screening
including a PPD skin test and chest x-ray for all Class A or B immigrants within 30 days of receipt
of notification of their arrival. The Contractor will additionally obtain sputum cultures x 3 if a
clinical evaluation by a qualified medical provider or chest x-ray interpretation reveals suspicion
of active disease. The Contractor shall provide for appropriate follow-up for these immigrants,
complete the CDC 75.17 form and return the completed form to the State. The Contractor further
agrees to notify the State if the immigrant fails to appear for the required TB screening within 30
days of receipt of notification of their arrival.
6. The Contractor shall,through the services of Personnel Health Aid III's (1.5 FTE), conduct an
outreach program to ensure that patients receive appropriate information and education and assist
with follow-up needed to fulfill requirements as listed above. These workers shall be bilingual.
Services provided by these workers shall include, but are not limited to:
1. Ensure adherence to and the completion of therapy for TB patients and implement
outreach and contact follow-up activities for all newly reported cases and suspected cases
of TB, paying special attention to patients with potentially drug resistant cases and their
contacts.
2. Ensure completion of therapy through Directly Observed Therapy(DOT), individual
accountability, incentives and enablers. If the national objective for the completion of
therapy(90%of reported cases) is not met or exceeded, the Contractor shall evaluate
reasons for nonadherence,devise new strategies, and discontinue lower-priority activities
(e.g. routine skin testing programs where few new infections are found)and use those
resources to ensure completion of therapy for patients with active TB.
Page 4 of 7
7. The Contractor shall provide the State a narrative report for the initial term of this Task Order,
January 1, 2000 through and including June 30,2000 by September 1,2000 which includes:
a. Progress in implementing outreach activities, results of the evaluation of those activities
and whether county TB Program Objectives were met.
b. A statement of any difficulties or special problems encountered in meeting the agreement
objectives .
c. A statement of action plans designed to overcome or address difficulties and problems.
d. A statement of population served and the special needs of those populations which have
been met through the agreement, non-compliant patients, children, foreign-born. etc.
e. A statement of time spent by the outreach workers in TB prevention and follow-up
activities.
8. The Contractor shall provide or arrange for quarantine services for patients requiring isolation.
The Contractor further agrees to provide a written financial statement of need completed by a
licensed social worker, indicating whether client has other financial means to cover costs of
quarantine.
9. The State shall provide statistical analyses upon request by the Contractor regarding the
Contractor's TB Control Program.
10. The Contractor shall submit Contact Investigation Reports to the State, as required by Centers for
Disease Control and Prevention (CDC),(copies attached and made a part hereof as Attachment
E). The Contractor and the State agree to collaborate in automating data collection and transfer of
these reports.
Reports of all TB Contact Investigations provided during the initial term of this Task Order,
January 1,2000 through and including June 30,2000 shall be due to the State September 15,
2000.
11. TEI Control services pursuant to 25-4--513, 8 C.R.S.,are provided at 80%from state funding
sources and 20%from the county in which the recipient resides. The Contractor shall be
responsible for the remaining 20%, which may be contributed in the form of an in-kind agency
match.
C. COMPENSATION.
1. The State shall cause to be paid to the Contractor an amount not to exceed THIRTY TWO
THOUSAND TWO HUNDRED FORTY TWO DOLLARS($32,242.00)under this Task
Order. Of this total amount,one hundred percent, is derived from a funding source of the
Federal government.
Page 5 of 7
2. 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-EIGHT THOUSAND
DOLLARS($38,000.00) Statewide for Tuberculosis Direct Observed Therapy for State
Fiscal Year 2000. 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.
3 The State shall reimburse the Contractor for expenditures in accordance with the budget below.
The Contractor's transfer of funds from one line item to another must have prior, written approval
of the State:
Description Amount Funding Source
Tuberculosis Control $30,522.00 Federal
Chest X-rays $ 1,000.00 State
Medical Consultation $ 720.00 State
Direct Observed Therapy As Administered State
@$12.50 per visit
TOTAL:$32,242.00
D. PAYMENT MECHANISM.
1. To receive compensation under this Task Order,the Contractor shall submit a signed monthly
billing statement, an example of which is incorporated herein by reference. made a part hereof,
and attached hereto as"Attachment F", within sixty(60)calendar days of the end of the billing
period for which services were rendered.
The billing statement shall:
• Reference this Task Order by its Contract Encumbrance number,which number is
located on page one of this document;
• State the applicable performance dates, the names of payees,and a brief description of
the services performed,total expenditures incurred,and the total reimbursement
requested;and
• Reflect the total program cost as the sum of the"Local Agency Match" and"Amount
Requested for Reimbursement"on the monthly billing statement(Attachment D). The
"Local Agency Match"shall document the Contractor's 20%contribution of program
costs.
Billing statements shall be sent to: Juli Bettridge,DCEED-A3,Colorado Department of
Public Health and Environment, 4300 Cherry Creek Drive South, Denver,CO 80246.
E. ATTACHMENTS. All attachments are incorporated herein by this reference and made a part hereof as if
fully set forth herein. In the event of any conflict or inconsistency between the terms of this Task Order
and those of any attachment hereto,the terms and conditions of this Task Order shall control.
Page 6 of 7
IN WITNESS WHEREOF,the parties hereto have executed this Task Order as of the day first above written.
CONTRACTOR: STATE:
BOARD OF COUNTY COMMISSIONERS STATE OF COLORADO
OF WELD COUNTY Bill Owens.Governor
(a political subdivision of the state of Colorado)
>7L C
By: i By: ,< -
Na : Barbara J. Kirkmeye Or die Executive Director
Title: Chair (01/19/2000) Department of Public
FEIN: 84-6000813 Health and Environment
ATTEST: PROGRAM APPROVAL:,.,rd�`I�v li��►
(Seal) i w
'1861 t 0 9
By: _a_„ By:
44HK4CIVXMXXK2F%
e �f 'i„��� � L.A. Koles i,Jr.
aWJ�( :�a�
Deputy Clerk to the B.a d '
APPROVALS:
OFFICE OF THE ATTORNEY GENERAL OFFICE OF THE STATE CONTROLLER
Ken Salaz �t feral Arthur L. Barnhart,State Controller
JEY ENERAL n)
By: ,� � By: k/1, e,j
JAMES E. MARTIN, JR.
ASSISTANT ATTORNEY GENERAL
STATE SERVICES SECTION
Page 7 of 7
Attachment A
TUBERCULOSIS SUR\ _ILIANCE AND CASE MA' DEMENT REPORT
ONSIONIMIIMONIMIEMEMIMIMIMIMMISMP
Colorado Department of Public Health and E.wk.wr n.w* DCEE4300 D-TTB
y Creek Drive South
TnaDManbak Centel Denver,Colorado 00246-/630
• (303)692-2679 Phone (303)782-0338 Fox
PATIENT INFORMATION
Date of Birth Cy of Birth Month Year
Name
d ountr Arrived in USA
USA ii
Address cit0 Canada,Japan,Western Europe,
Home �' Australia,New Zealand Refugee:
Phone: County of Mexico.Central or South America 0 Yes
Work Phone: Residence ❑Akica Middle East ❑ No
I_
Sex: trace 0 China,India.Central or ❑Unknown
Male ❑White Ethnic orign Southeast Asia,Indonesia, Alien Numbers
❑ 0 Eastern Europe,Russia,Ukraine
❑Female 0 Black Hispanic
❑American Indian, ❑ Non-Hispanic 0 Unknown l enght of residence
Agskan Native 0 Unknown _ in Colorado
Marital Status ❑Asian/Pacific Island
❑Unknown
AGENCY SUBMITTING THIS REPORT
Agency County
Arno"Name: J
Agency'Address:
Phone:
Name of Patients Primary Care Physician:
Address; Phone:
My: Z :
MOST RECENT SKIN TEST
Previous If positive,is this a skin test
Typ� Results: induration Positive PPD conversion negative to positive
❑Mante x-Aphold 0 Negate ❑Yes within 2 years:
O Ti mtpaa Apisol ❑Negative ❑Yes
Tim ❑Not Done Date PPD Read ❑No 0 No
O f Date of last 0 Unknown
❑Other(specify) 0Unknownol negative test
❑Other'(seedy) 1 1
X-RAY FINDINGS
Previous . s X-ray taken by:(A®emrys Name):
Date of x-ray .A�X-ray 0 stable
_I_J___. _1____I___ worsening RainXrayto:
�knpovin9
Xray results: Abnormality ❑Untnown
O Normal ❑Caveat);
❑Abnormal ❑Noncavitary Consistent w/TB
❑Not Done 0 Noncavtta y Not Consistent w/TB Note CDPFE wllr sepantdyathdr x-ray
❑Unkrown 0 Other(Specify) Note:
and recommendations
CLINICAL
Date of Onset of Special Condition=
Symptoms: S oms: ❑Pregnant EDC: /
❑None 0 Fever j�1 0 Postpartum Breast Feedsg
❑Productive-Cough ❑ ONightther
Sweats pecify) 0 Other(Specify): .
❑Height Loss s 0 Other(S.
❑weigh --------
_Date;
Name d Person compldin9i__
Comment= TB-17 021`.
ectacnment A
nellelti Name: wa a ram: , •MIIM.MrOccupation Yes No
Yes No
Care
❑Hugh Cue Worker 0 0 fbmetess wilNn past year 0 0 Diabetes .
O Cortectbnel Employee 0 0 Resident of Correction Facility 0 0 silicosis
O itigrabry Meultural Worker et time of Diagnosis 0 0 CanoeMAaignades
❑Hot 6aployed within last 24 months H Yes. 0 0 lmmonsuppressive Therapy
o Unknown 0 0 Federal Prison ❑ 0 Gastdomy
❑O0w0oc ation(specify) 0 0 State Prison ❑ ❑ Hepatitis
O 0 Local MI 0 0 Kidney Failure
O 0 Juvenile
How many other persons In household G ❑ Other Yes No
besides patient? 0 0 Exposed to TB
❑D G 1-3 G 4. 0 0 Unknown
0 0 Previous Diagnosis of TB
Yes No Date: / /—
On Mediations that may have 0 0 BCG Vac motion
interactions with anti-TB drugs? 0 0 Resident of Long Term Care
o Yes 0 No Specify Facility at time of Diagnosis? Date: / /_
If Yes.
G 0 Nursing Home Yes No
Yes No ❑ 0 Fbspltai 0 0 Prior HIV Test
0 0 Residential Date: /
❑ 0 Exce'riesssive
a Al Use ❑ 0 Mental Health If yes.Were(Site/Provider)
❑ 0 ��ef t ng clotohol Mann 0 0 Alcohol or Drug Treament
❑ 0 Plonarnjeding Skit Drug Use G 0 Other Pos Neg
❑ ❑ Unknown ❑ ❑ Result
-
TB FOLLOW-UP
Con6mted diagnosis of TB? ❑Yes 0 No 0 Suspect is patient in Insolation or in need of Isolation/quarantine?
If confirmed fist primary s8e__
0 Yes 0 No
Secondary site: If yes.describe:
Was a contact investigation initiated: 0 Yes _G No
Hospital Admission: If yes,is a Contact Investigation form needed? 0 Yes 0 No
Hospital: Date sent / /_ By whom?:
Admission Diagnosis:
Date I/
LABORATORY
SMEAR CULTURE LAST POSITIVE Laboratory Submitted to:
Pos Neg Not Done Pos Neg Not Done 0 Colorado Department of Pubic Health and Envirome
❑Sixtus 0 0 0 0 0 0 Date// 0 Other Laboratory(specify)
❑Urine ❑ ❑ . ❑ ❑ ❑ 0 Date JJ
❑Gastric ❑ ❑ 0 o ❑ 0 Date J_f___
❑Other 0 0 0 0 0 0 Date_____J Date: /_J
T"E'TMENT S•U"CEINF0 " ' MTIIN
❑Current Person Who Exposed eels Palen(
❑Past —> I❑Completed MI course Haire
0 Started but std not complete is course Address: Plane:__1
0 Unknown,if completed full course City: State: Zip
If treated in the past was this ton ❑Active Disease Closeness of Source to Case: Source Sputum reside
0 Preventive Therapy 0 Household 0 MTB CUWre Positive
0 Workpta e 0 AFB Smear Positive
DOT By: Other ❑ Smear and Culture Negative
Dm Regimen:(Mark all that apply) Date Started ❑ 0 Unknown
/ 0 Unknown
BarYs�d _____mg Laboratory_-------
Rifampin _mg —/ /
Pyradnauide mg //
Ethsm butol _raw —/-/--
Streptomycin _raw //
F_tlrio nangde _rw //
.
Other(specify)
Attachment B
PATIENT FOLLOW_UINFORMATION AND TRANSFER infatuation Reply AN FORM (TB-10)
tse
TO: FROM:
•
Patient's Name: — SEX Marital Status
M F SMWDSep
Address: Birthdate / / Race
City,State,Zip County:
Phone Number.
ACTIVECASE: YES_ NO__.
Confirmed by Labor PCP diagnosis?:YES_.NO__ If yes,date of diagnosis:_ I /_
Date of TSC skin test t I — Result In MM. Suspect
Form: Pulmonary_._ Extra Pulmonary(specify site) —
LATEST BACTERIOLOGICAL STATUS: Not Done
Oat IUort amour MSS Mat And Cin RaultOS Oshe IS Posies taeoto,wen.,.a .mK
-----------
SpanWtou
_
on.r lsawh ) Medications and dosage
DRUGS: If patient on drug therapy
Date started:._L..1--
Date stopped:Jam_
Number of weeks on DOT:
If patient NOT on drug therapy,give mason:
Most recent X-ray results/date(s) •
Previous Nospltalizat for TB: V msret
Phone fk
Primary Care Provider..
YES.._ NO_ Medications and dosage
Date of Sidn test_Ll—.
Date stare' r / .
Date stopped medications:-- I
Reason stopped: Medication then by whomt ....«
Date of relocation:
If patient has moved or relocated,
Cternalinfra
Colorado Department of Public Health and Environment Name of Person completing the form! Date
Den Cheny Cnserat!lo 0222City. 630 O -2679 78•10O°re �
Denver,Colombo 60222-
Attachment C
REPORT OF VERIFIED CASE
PIIINn.s Name: (F4.n (NA.1 OF TUS,ERCULOSIS
nun
Stint Address: Zar Goal
soot.city.moo
U.S.DEPARTMENT OF REALM&HUMAN SERVICES
(\^J,�Y�^ t FOR DISEASE HEALTN SE VICE
�/i� v CENTEas ND tnnr IN IOOCL
REPORT OF VERIFIED CASE OF TUBERCULOSIS • AND Mawr SERVICE
ATLANTA,GEORGIA 10333
McIM.1�1.�Y.FM.N lean APIIIOVED OMS NO.15114115 np.5.1.I IRS
NO..Meeee
Initial Drug Susceptibility Report (Follow Up Report — 1)S ate Reporting:SOUNDEX Year State Case
i 00 Counted: Number:
JII Spicily:
Alpha Stale Code I City/County Cue Number:
\.__ ]
Submit this report for all culture-positive cases. \
X33. Initial Drug Susceptibility Results:
Was Drug Susceptibility Testing Done: o❑No t❑Yes S❑Unknown
If answer is No or Unknown, do not complete rest of report.
If Yes. No.
Da Yr.
I I 1
En
ter Date First Isolate Collected 1
for Which Drug Susceptibility Was Done? 1
34. Susceptibility Results:
Resistant Susceptible Unknown
Msl Done
Isoniazid i❑ 2 3 a❑ .
Rifampin I❑ 2 3 a❑
Pyrazinamide i❑ 2 3❑ a❑
Ethambutol I❑ 2 3 a❑
Streptomycin I❑ 2 3❑ 7❑
Ethionamide I❑ a❑ 3❑ 7❑
Kanamycin 1 a❑ 3D E❑
Cycloserine I❑ a❑ a❑ s❑
Capreomycin I❑ a❑ 3O 90
Para-Amino I❑ 20 3 9[3Salicylic Acid ❑ s❑
Amikacin I❑ 3 a Rifabutine I❑ a❑ a❑ s❑
Ciproftoaacin I❑ a❑ 3 s❑
Ofloxacin I❑ 2❑ 3❑ s❑
Other i❑ 2 3❑ e❑
Comments:
[ —
fitatelel.�a —i we NFdiese i rlalw iws0"rat.we M...SS e. - alas w Paid F Mn ReM.._S ea is ems.iSr sinews papa and ee MM thew'
-- --- - 1 el Copy-State REPORT OF VERIPED CAE OF TUDERCUDSIS Fellow W Riper
Attachment C
REPORT OF VERIFIED CASE
Pi1NM":,Namr. dra.o (M.(.I OF TUBERCULOSIS
Ilse.,
Itrnt Address: — +�eeorl
(wwwb.,.Moms.Car.SlMN+ _ .......... _......__ _.__.
US.DEPARTMENT Of HEALTH 0 HUMAN SERVICES
CDC
PU&JC HEALTH SERVICE
�/✓ V CENTERS FOR DISEASE CONTROL
REPORT OF VERIFIED CASE OF TUBERCULOSIS TANTA.PREVENTION
RAND R.GEORGIA 30333
awawaaanrraawra rpm MPPROYEO OMi N0.N/aNtl Eq.WM MIS
Case ompletion Report (Follow Up Report - 2)
SOUNDEX Sate Ripening: Year
1 a ❑ Specify: Counted: State Case
Number:
j
City/County
Alpha Stale Code Case Number:
If Yes.Dale Specimen Collected If Yes.Date Specimen Collected on
35. Sputum Culture on Initial Positive Sputum Culture: First Consistently Negative Culture.
Conversion Documented: Mo. Oa Yt. MO. Oa Yr.
OD No t O Yes 90 Unknown I I 1 I I
36. Date Therapy Stopped: 37. Reason Therapy Stopped: -
Mo. r7I I +Yr. O Completed Therapy 30 Lost sO Not TB TO Other
20 Moved 40 Uncooperative or Refused 60 Died 90 Unknown
36. Type of Health Care Provider: 39. Directly Observed Therapy:
If Yes,Give Site(s)of Directly Observed Therapy-
ID Health Department o0 No,Totally Sell-Administered
to In Clinic or Other Facility
x❑Private/Other 10 Yes.Totally Directly Observed
20 In the Field
20 Yes,Both Directly Observed 3O Both in Facility and in the Field
7❑Both at Department and Self-Administered
and Private/Other Weeks
s0 Unknown
9O Unknown
Number of Weeks of Directly Observed Therapy:
It Yes.Enter Date Final Isolate
40. Final Drug Susceptibility Results:Test Collected for Which Drug Mo. Day r.
Was r- up Drug Susceptibility Testing Done? 00 No 10 Yes 90 Unk. Susceptibility Was Done: I I
If answer Is No or Unknown, do not complete rest of report.
41. Final Susceptibility BesL4aDt Sasslais birdlime Slalom
Results: Isoclinic( Capreomycln +❑ x❑ a❑ 9O
Isoclinic( +❑ a0 a0 9O
a❑ '❑ Salicylic Acid +O x0 30 9O
Rifampin 1❑ a❑ a❑ •O
Pyrazlnamide +❑ a
EI 30 .O Amikacin t❑ a❑
Rilabutine tO 2O a '
Ethambutol t a a .O
O
Streptomycin +❑ a❑
30 9O Ciprolloxacin I❑ eD 3 .O
s❑ '❑
Elhionamide +❑ a i
30 O Ofloxacin +O 2❑
Kanamycin 10 aD 3❑ 'O Other ID a❑ ° '
Cycloserine ID aD 30 '❑ .
`Comments:
m macs,war• H swab.INN Meld doss ono Si nests wwwawes papa salsa Pd be,AdNM,
(r+nnwlmNiaiiiia idn I#.Sd rw+H' w�Nie1"3 „N'I..'Mmere w — 4C US63wt
COC TLC
EV awrreelMMArdResiwMb.r aNm REPORT Of VERIFIED CASE Of TUeEOC1ADSS rdov Up 519 '
1st COPY—State
eoetxse REV Inn
Attachment C ',
OCOl,ATIONAL sUPPlE1A@/f OF
Pedant's Rime: ifuam Pull — VERIFIED CASE OF (191
(tail
Stress Address: — 7r4Cadf c
faaaau,swat.coy.soul
u.f.DEPARTMENT Of HEALTH IPUBL�NIYAN� •
v OCCUPATIONAL SUPPLEI,IENT TO THE REPORT OF CENTERS waoteF.uE
VERIFIED CASE OF TUBERCULOSIS (TB) AND ATtANTA.Oral
PO APPROVED Ole NM 9910an9 Fad.Da INN
aewerenaa
RN
SIta b: MontlrYaw
SteleRepelling: State Case J me. Yr.
wily. Number:
Alpha Su 11 le Code City/Countyer: i j I l I I ( I I1
I
Case Numb
eI.Was this person employed at the time he/she was diagnosed with TB? 2.What was the reason the iperson was not employed?(Deck only one.)
(Mark'yes'If the person had a job,even if he/she was temporarily not at home.etc.))
work due b a reason such as illness or vacation.) i❑ Student 5❑Institutionalizedg.Institutionalized(e living in prison.jai,nursing
20 Retired 6❑Disabled by a physical,mental,or other health condition
1❑Yes(I/yes,skip to question 5.) 7❑Other(may)
30 Homemaker
o❑No
9❑Unknown (If unknown,skip to question 3.)
40 Unemployed 9❑Unknown tha.Has this person ever been employed. 4.What was the approximate last date 5.Was
isthe person of active duty with the tinned
nfor•few days?
this person was employed? forces
iagnosis?
Ma. Yr. m❑Yes e j No 9❑Unknown
I Yes o❑No sip Unknown I ( I I
(IF NO OR UNKNOWN,STOP HERE.) I J
7.Occupation: dotn 7
I For questions 6 and 7.describe this person's chief job activity or business. e,w kind of work was this person 9
N this person was not working at the time of diagnosis.giveinlonnatlon for
hisaer
most recent the one at r°hbkh he/she or sworked the most Mursmore than one job,describ e. registered nurse, I manager,supervisor d older department,
gasol amine r,cake Nicer,etc.)
f•Industry:
a.What kind of business or Industry did this person work for? b.What were this person's most important activities«darks?
(Oeaabe the activity*Horatian*lyre employed.)
(ey..hospital(newspaper paining mat order house, (e Sealin king g hiring s•supervising order dec
porderdecks,
assn+nVL'e RwaAanXu'k'y'eCvl,UMW.SO assembling engines,
cakes, Ma)
9.In addition to the lob described in questions f and 7.has ids person
a was this person...(Check ONE) 9.
wodad('for pay or as•volunteer)or lived in any ofthe following
«business or �7(Check al that apply.I riot already dilated in
7❑ aapbyeedaPiWATe14Rry or coIT oammpartyquestion 6 all 7.)
d an MdlMduslforwW++,salary or YES NO Ute.
to employee of a ltSonENNOTfDRFROFIT,tsxexempL or a. NursMa lane - —._._.._.____. 1❑ 0❑ 9❑on etc.) b. Rosetta----•--- _..._. ❑
charitable 7 0❑ +
M❑ load GOVERNMENT employee(city,county. 1❑ 0❑ SO
90
40 stab GOVERNMENT employee a Hospbe—•• —.-___.-__-- 1❑ 0❑ 9❑
SO federal GOVERNMEIfT employee d. 'Ckscel laboratory_.-__ --_.. 1❑ 0❑ 9❑
s❑ SELF-EMPLOYED M own NOT INCORPORATED business. e. Dodoes office _.
profess anal practice.or tarn f. Ambulance service -_.—.—..—___.__.__.._ 1❑ CO +❑
70 SELF�APL.OYED in own INCORPORATED business. • g. Volunteer oroenintlion providing service t❑ o❑ 9❑
or turn primarily to ADS patients •—_______...._.l eroddng WITHOUT
1❑ o❑ .O
'a❑ eroding wfTT10lJT PAY in larmmly business«Penn R Center for alcohol or drug abuse treatment._..
: .. .. .... . . I. Shelter for homeless persons_.._..._....... .
1❑ CO 9❑
from ALL sources in the . -1❑ '0❑ 9❑
. 10.Whatwas this PemmlOfli bid household income j. 'Funeral home _—_.— --.
*Sender vile prior b the yard Magi.TB
- ._—_—..—._.... 1❑ o❑ +❑
1Fcrnw�molis,t Fa person k resod with TOM1995. ,dent Ns«Mr 1994 -k Morgue -- - a❑ 0❑ 9❑
had, to lkane nt le wiliness,roomsIcirdng a sk+��Se tMoonr. ; L Prison«ell -
Il F°kwa�Mnents.+add seat tly,tper weds
endorsement .Mid keerws m. lwok«wde+ l ° _._._._._ ,❑ o❑ +❑
vies a loss rnM'Lass'above an, amount.)
-_-----_
_ ANNUAL
0❑None 'Ow I i :Da
'AMOUNT 'DOLLARS .
erne 9aeYMala.
M era UrduabaaeawbSaaa'�Aeidetr ea sot alwit dbw'
Gyp�ns�s�.p��/9a�iwe�mbia Yrw.rah sasiwd Mewasaaha rww'aPre r.v.H.mw. 1201. dMbw a...4 a�maMwRa .law►wia.1°a'ae®mF~ tc+060
paaaG11iM Pnr-au.~6LMw9�t a~° m d _____'+A...wrvw+paaoeaWam Ma°MOd Ma""9""a _k al Ida
weaken al tem.S Is see eaaaeaa WM0 orate se le mum sot nab . eU be real f wW.iiwanwa Maser
......................«.6.aaw ass ASMst.,, a Faro Nis p w+w SanS am Mt *0*
'raeralrnaera Mawersa6NM,MaRIMaasw'baa - _ areleA7101ML a nefl 10 vie'Evart OF VOWED cAaEOFis Pap
Attachment C
°CCIRA VERIFIED
BloPlEMENTcAsli of 1°ITE REPORT OF
n!BE CtA (Tel
r�r71�1'
1
lilies this person over lived outside the United States?
1�1. »M�y poison's household,whether etnd Mhos la nlstsd tip Yes Op No Op Unknown
Ss sits pew,ever lied sinus TB?(Lc,
the same household.) sister.son.
darrglter,erany ohs person WingII span
cowmowhine:
tip Yes 0O No cep Unknown person yes.s lits nhv time:
14.M the lob described in questions 0 and 7,
COMPLETED?TED7(Check eiv one. does(did) ?( person work M a health-related
1J.tor much school has this pesos or degree received.) doeupation?(such as a nurses eke a physician
for the highest feud or grade already completedor in a job h a health-care organization or facility
O6❑ Associate degree in college or a clinical laboratory.)
of❑ l grades completed junior 07❑ Bachelors degree in college(e.g..BA«BS)
03O Elementary ordootd. school h❑Yes o❑No 9❑ Unknown
0q❑ Masters degree(e.g..MA,MS,MEEng,MEd,
m❑ Some high Whod,rodpbma MSW.MBA) ((F NO OR UNKNOWN, STOP HERE.)
Or❑ High school graduate(dooms or e0„haiasl dg❑ Degree above Masters level(e.g..MD.PhD.
os❑ Some college,no degree DOS.DM US.JO)
has Mk in a healthcare
ids*henna, a to oinks'wars IS Y. r„h xJ rrent a toshomated occupation.This�gtotad be he e recent eaarnssjjob o�esated In PAS 6 and 7.
Health-Gaye Worker Questionnaire we�+�°^•�•`s"'d Y°°rat°"�' Npe
16. the of toddy was tr place pere°h w°'ked i7.Mp in the ,! h«" ere t e Inpatient beds
were in the `MK"ethopatienweds
1S.ryhat was the location d the workplace? -
t❑Federal t❑No inpatient beds 5❑300.399 beds
CRT a p 400-499 beds
:❑City(municipal).couty,Or state x❑ 1-99 beds
Slate: 30 100-199beds 7❑≥500 beds
N .
Jp Private
Was aro a n tl city& 0 a❑Unkn0vrm 4❑200-299 beds a p Unknown
I❑Yes on No ❑Unknown
19.8 the person terminated
20.Where M to facility did this person primarily work? (Check only ONE)
ltdate was the approximate bet! to the dale 211 or recovery room
a the the=began employment priorOt❑ Admitting120 Operating
a diagnosis,whet was the office h0❑ Outpatient clinic
spe worldoehelse
stopped waiting at this facility? ea❑ Business office hA❑ Pathology/autopsy
Mo. __ r� 03O Emergency room
ego. rr. Is Pediatric ward
I040 Facility-wide W .--- es O Intensive-care unit is❑ Psychiatric ward
«❑ Laboratory
t7❑ Respiratory therapy
cep unknown t❑Currently work here 160 Surgical ward
9❑Unknown d7p Laundry
ee❑ Medical raid t9❑ Other(specify)
21.0W this poison usually work in a location were patients It lop Mutipk wards«e UnknownUnknown
active 7B received preen service loA.arean.wad tit❑ necelogy ward Oa O
l Yes op No cep Unknown
22.Job Activities: (For the tobwMhg hld tasks,dwndrYsdkAdes that to person peed es a matins Ped of Ws kb.) rEs NO UNK
YES NOt1NK. h.Pf0Oessedlaboratoryspedrnenhsf« 1p 0O e❑
tip 0❑ cep myoobadedd(AFB)smear or«Nae—__--_— tip 0❑ e❑
.
a. Talked cosh Port ---'---- Performed or assisted with autopsy ._...._•—counsezang b, onsanahe parent leaching«_—._.. r❑ °❑ ep L P(. Penton ed or assisted with bronchosospy -•--_._.. t❑ °❑ *O
•
1❑ 0O e k Performedorassistedwihendouedieal 1p °p a❑
e. Administered orallneckalierxt tp GO ep kthrbatiom«auctiatrW _......_ '_
d. Gana iris-dons or TB skintetu ---• 1 Op e❑ I. Performed dhae ltolized « its e❑ a❑
a Emceedaca cia rooms .....-^---.... administered eslphy lot megur.o s _._
1. Assisted inpatients sir°dtvOies d daily MW tip ep s❑
(e.g.,bathing.changing dresdngs)--..........__....._...
g. Collected sputum for obi de4W(Alm) r❑ cep S
W. Hos Ws person ever had BCC Vaccine(Lc.aoohaton against TB)t
Ma. --:.:F ----
I O Yes Date of BCC:
0O No cep Unknown
Comments: ......_—.
,-.......er.r. Opt .....aM'R r TOME REPORTS YElweDusE Oe 1° Pans
•
Alien(Allen!.Name,Address, Phone): IMMIGRANT A• REPORT ON ALIEN WmI TUBERCULOSIS
40C.AL HEALTH OFFICER:
EV ;this person recently entered the United States and is refined to you because
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 t hemoprophylaais sal Is referred to
you because you may wish to initiate preventative treatment. Your Initial
Six:(,3 M ( J P DATE OF BIRTH(Mo.,Day,Yr.) 1/21/64 evaluation would be appreciated. Please check the appropriate hoses below
and return this form to the State lfealdr Officer.*
E 3 CLASS 13-I -Tuberculosis,clinically active,not infectious If the alien does reponrby • please check ben[ J and
forward this form Sutellealth Officer.* Retain for you anoeds
( J CLASS D-2-Tuberculosis,not clinically active,not infectious the accompanying report of examination performed abroad(O14157).
Vaasa eea sad dugs re s4 Cann,*Maw Caw!awl ri,wda,
Your Initial Evaluatlont tiles Patient Received Chemotherapy/Prephylaals In the past!
A.Direct Smear(in U.S.) C.X-ray(abroad) D.Presumptive Diagnosis [ I Yes [ )No 3 Unknown
f ]Positive I
I
Normal Pulmonary TB-Active F.Arnett prescribing Chemotherapy/Prophylaxis?
Il )1 Negative Abnormal Pulmonary TB-Not Active ( J Yes I I No
Not Done Not Done Pulmonary TB-Activity Utdctermined Signature of Physician Date of Evaluation
Unavailable Uatrappuuimonary TD
B.X-ray(in U.S.) Non- Abnormality
Normal No Abnormality Name of Health Depanment
Abnormal
((( Not Done •l
This form is not intended to substitute for normal NOTE TO STATE HEALTH OFFICER:Upoa receiving Division of Quarantine,Data Mgr(E03)
procedures for reporting tuberculosis to the state this completed copy from the Local Health Officer. Centers for Disease Control and Prevention(CDC)
. . Health Department I please forward to:
Atlanta,Georgia 30333
• CDC 75.17(Rev. 12/94) CLASS B LOCAL HEALTH DEPARTMENT COPY
COLORADO DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT
TB CONTACT INVESTIGATION RECORD
Name of Reporting Agency: Date:
w Name of Source Case: Site of TB:
a Date Case Reported:
Type of Preventive
Contact PPD Results(mm) Therapy TB Disease
N fff Age (see codes X-ray
. D & Yes
below) Baseline Retest va." Date
Contact <15 15-35 >35 Date Date Result No Tx/Date Continents
Name:
BD:
Relation to Source:
Name
BD: •
Relation to Source:
Name:
•
. BD; •
Relation to Source:
Name: •
BD'
Relation to Source:
•
Name:
BD:
Relation to Source:
'Close Camact(Ck persons wfw have shared air with a known or suspected case of TB for prolonged and frequent periods online(e.g.household members,work associate—depending on type of work/cavkomaem)
paler Comm(CC): persons who do not meet the criteria of■close contact,but have had limited exposure to a known or suspected TB case. Skin testing for OCs is Indicated only when It is likely that transmission to this
group has taken place(e.g.signiaeantly large number of close contacts show positive skin tests)
TB-3 0V22/97
ATTACHMENT F INVOICE NUMBER
CONTRACT REIMBURSEMENT STATEMENT
TO: FROM:
FAX: ( � DATE OF EXPENDITURE:
TYPE OF FROM: Final
PROGRAM: Bill?
0 Yes
FEDERAL ID TO: 0 No
NUMBER:
Description of Expenditure Local Agency Match Reimbursement Total
Amount Requested
GRAND TOTAL
This is to certify that the above expenses were incurred per Contract# and we are requesting reimbursement for same.
SIGNATURE(CONTRACTOR): DATE:
I hereby certify that all contract requirements have been met and the amounts are correct. Payment is authorized.
AUTHORIZED DESIGNEE (STATE): DATE: es ,
Coonaaar Nodded ora:mbw.damt Awaut
0Yes ONo Waal:
Hello