Status Adjuster LTBI and Abnormal Radiology Reporting

As of October 1, 2018, the new Tuberculosis Technical Instructions for Civil Surgeons require reporting individuals diagnosed with LTBI to the health department of the patient's residence.

Please complete the data collection tool below for patients that:

1. Have been diagnosed with LTBI

2. Have abnormal imaging not consistent with TB and need to be seen by our clinic for further evaluation.

For those with abnormal x-rays concerning for tuberculosis, please continue to alert us. The information (e.g. radiology report) can be faxed to 206-744-4350 or you can call us at 206-744-4579 and press option 1 to be taken to our intake line.

Please inform the applicant that you will be sharing their LTBI diagnosis with Public Health Seattle & King County and that they can expect a follow-up text message about LTBI.

LTBI diagnosis will not affect their application for status adjustment, but they are strongly recommended to consider treatment to prevent progression to active TB disease.

Thank you!

In early 2020, we created a Frequently Asked Questions (FAQs) document to answer some common questions civil surgeons may have about reporting LTBI in King County. Please download the documents here:

Attachment:Civil Surgeon FAQs_updated 15may20.pdf

Reporting Civil Surgeon

* must provide value

Reporting Civil Surgeon Phone Number

Does this patient reside in King County?

* must provide value

Yes

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Please do not use this survey for status adjustment applicants who reside outside of King County (even if your practice is located within King County).

For a list of other health jurisdictions, please follow this link.

For other counties, you must use the WA State Civil Surgeons LTBI Reporting Form; please follow this link to download.

Patient Name (Last, First, MI)

* must provide value

Date of birth

* must provide value

M-D-Y

Sex

For follow-up purposes, will this patient require an interpreter?

* must provide value

Yes

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If yes, what language does the patient speak?

* must provide value

Is patient's radiology normal?

* must provide value

Yes

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Abnormal CXR Referral: Please complete the fields below. You may also fax us (206-744-4350) with the information below + patient demographics, including patient phone number.

Please upload the patient's radiology report:

* must provide value

Upload file

Please upload a copy of the QFT results:

* must provide value

Upload file

Please upload a copy of the patient's I-693 form:

* must provide value

Upload file

Register the patient with University of Washington Medical Center in order for the image to be viewed electronically by calling 206-744-8845.

Please enter the patient's U# in this field:

* must provide value

How will you submit CXR or CT images to us? Select one.

* must provide value

Mailed disk

Pushed electronically to Harborview Medical Center Radiology

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Date disk was mailed:

* must provide value

Date images were pushed to Harborview:

* must provide value

The patient's home address (number and street)

* must provide value

City

* must provide value

Zip Code

* must provide value

Patient phone number:

* must provide value

Please allow 5-7 working days for processing after we have all the required documents. Please have patients call your office for any updates. Please check the box to confirm your acknowledgment of this timeline.

* must provide value

I understand

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If radiology is not normal, please call the TB Program at 206-744-4579 and press 1 to be taken to our intake line. This form is only for patients with normal radiology.

Date of patient's appointment (month/day/year):

* must provide value

M-D-Y

The patient's home address (number and street)

* must provide value

City

* must provide value

Zip Code

* must provide value

Home Phone

* must provide value

Cell Phone

Country of birth

* must provide value

IGRA test type

* must provide value

Date IGRA obtained (month, day, year)

* must provide value

M-D-Y

IGRA result

* must provide value

This form is only for individuals who have positive IGRAs. If you have any questions or concerns, please call the TB Program at 206-744-4579.

QFT nil

QFT TB1

QFT TB2

QFT mitogen

T SPOT nil

T SPOT Panel A

T SPOT Panel B

T Spot Positive Control

Date of Chest X-ray

* must provide value

M-D-Y

Did the civil surgeon, or will the civil surgeon, start the patient on LTBI treatment?

* must provide value

Treatment Regimen

What is treatment regimen?

Does patient have primary care provider?

From what provider or clinic do they receive primary care?

Is patient insured?

* must provide value

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