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NATIONAL SURVEY OF TUBERCULOSIS DRUG RESISTANCE
KWAZULU NATAL
TB SUSPECT IDENTIFICATION
Surname __________________________________________ Name _____________________________________ District _____________________________________________Hospital/Clinic _______________________________ Hospital/Clinic tel ___________________________________ Hospital/Clinic fax ___________________________ Town/village residing for the past six months __________________________________________________________ Has this person worked as a miner? y y y y TREATMENT HISTORY FROM EXISTING MEDICAL RECORDS
(Check through all available documents to determine whether the TB suspect had been treated/registered before)
If yes, what was the outcome of the last course of treatment? TREATMENT HISTORY GIVEN BY THE TB SUSPECT
(Ask the following questions to the TB suspect)
GO TO SECTION C1
GO TO SECTION C2
How long have you been sick?
Have you had the same symptoms in the past?
Have you had other symptoms of lung disease in the past?
Have you had chest x-rays in the past?
Have you had sputum tests in the past?
Have you taken medication for more than one month in the past? Yes
Have you ever received injections for more than one month?
Where were you treated?
Hospital
Workplace
When were you treated?
How long was the treatment?
<1 month
1-2 months
3-4 months
4-6 months
How many courses of treatment did you receive?
Should this suspect be found to have TB, what treatment regimen will you use? “ Regimen I (new cases)“ Regimen II (retreatment cases) Name of doctor/nurse ________________________________ Signature ___________________________________________ COLLECT THE SPUTUM SPECIMEN BEFORE ANY TB TREATMENT IS GIVEN
PLEASE ENSURE THAT THE COMPLETED FORM ACCOMPANIES THE SPUTUM SPECIMEN TO THE
LABORATORY
- THANK YOU -
Tuberculosis Research Lead Programme
Operational and Policy Research
Private Bag X385, Pretoria 0001, South Africa The
1 Soutpansberg Road, Arcadia, Pretoria, South Africa Tel +27 (0)12 339-8550 • Fax +27 (0)12 325-5970 Medical
Director: Dr Karin Weyer (karin.weyer@mrc.ac.za) Research
Laboratory enquiries: Jeannette Brand • Tel +27(0)12 339 8565 Council
NATIONAL SURVEY OF TUBERCULOSIS DRUG RESISTANCE KWAZULU NATAL
PRELIMINARY LABORATORY REPORT
REFERRAL

DISTRICT

RECEIVED
PROCESSED

SPECIMEN TYPE
SPUTUM ASSESMENT
MICROSCOPY RESULT
CULTURE RESULT
FOLLOW-UP REPORT

Susceptibility and identification test results to follow Tuberculosis Research Lead Programme
Operational and Policy Research
Private Bag X385, Pretoria 0001, South Africa The
1 Soutpansberg Road, Arcadia, Pretoria, South Africa Tel +27 (0)12 339-8550 • Fax +27 (0)12 325-5970 Medical
Director: Dr Karin Weyer (karin.weyer@mrc.ac.za) Research
Council
KWAZULU NATAL
FINAL LABORATORY REPORT
REFERRAL
DISTRICT
RECEIVED
PROCESSED
SPECIMEN TYPE
SPUTUM ASSESMENT
MICROSCOPY RESULT
CULTURE RESULT
DIFFERENTIAL TEST RESULTS
Biological
Biochemical
IDENTIFICATION
DRUG SUSCEPTIBILITY TEST RESULTS
Annexure 3
NATIONAL SURVEY OF TUBERCULOSIS DRUG RESISTANCE IN KWAZULU-NATAL
SELECTED TREATMENT UNITS PER DISTRICT
Patients
District Facility
Required Actual

Source: http://www.sahealthinfo.net/tb/tbkznannex.pdf

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