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RNTCP Request Form for examination of biological specimen for TB (Required for Diagnosis of TB, Drug Sensitivity Testing and follow up)
Patient InformationPatient name Age (in yrs):____ Gender: M F TG
Patient mobile no. or other contact no.
Specimen date ofcollection (DD/MM/YY) _______
Sputum Other (specify)______
Aadhar no.
Patient address with landmark
HIV Status: Reactive Non-Reactive Unknown
Key populations:Contact of known TB Patient Diabetes Tobacco Prison Miner Migrant Refugee Urban slum Health-care worker Other(specify) ______
Reason for Testing:Diagnosis and follow up of TB
Diagnosis (NIKSHAY ID_________________) Follow up (Smear and culture)
H/O anti TB Rx for >1 month: Yes No RNTCP TB Reg No ______________NIKSHAY ID:________________Regimen: New Previously TreatedReason: End IP End CPPost treatment: 6m 12m 18m 24m
Presumptive TB Repeat Exam Private referral Presumptive NTM
Predominant symptom __________________
Duration ______ days
Diagnosis and follow up Drug-resistant TB
Drug Susceptibility Testing (DST) Follow up (Culture)
Presumptive MDR TB
New Previously treated PMDT TB No ____________DR TB NIKSHAY ID: _______________
Regimen: Regimen for INH mono/poly resistant TB Regimen for MDR/RR TB Shorter regimen* Modified Regimen for MDR/RR-TB + FQ /SLI resistance Regimen for XDR TB Modified Regimen for mixed pattern resistance Regimen with New Drug for MDR-TB Regimen + FQ/SLI resistance Regimen with New Drug for XDR-TB Regimen with New Drug for failures of regimen for MDR TB Regimen with New Drug for failures of regimen for XDR-TB Regimen with New Drug for mixed pattern resistance
Treatment Month Week :____________
At diagnosis Contact of MDR/RR TB Follow up Sm +ve Private referral Discordance resolution
Presumptive H mono/poly
Presumptive XDR TB
MDR/RR TB at Diagnosis ≥ 4 months culture positive 3 monthly for persistent culture positives (treatment month _____) Culture reversion Failure of MDR/RR-TB regimen Recurrent case of second line treatment Discordance resolution
Test requested: Microscopy TST IGRA Chest X-ray Cytopathology Histopathology CBNAAT Culture DST Line Probe Assay Gene Sequencing Other (Please Specify) ____________________
Requestor Name, Designation and Signature: ________________________________________Contact Number:________________ Email ID:______________________
Results: NIKSHAY ID Generated: ______________________ CDL NIKSHAY ID: _______________
Microscopy ( ZN Florescent)
Lab Sr. No Visual appearanceResult
Negative Scanty 1+ 2+ 3+Sample ASample B
Date tested: ______________ Date Reported:_______________ Reported by:______________________ (Name and Signature)
Name and Type of referring facility (PHI/DMC/TU/ DTC/ICTC/ART/Medical College/DR-TB Centre/Private Others, specify): __________________________Health Establishment ID (NIKSHAY): _ _ _ _
CDL NIKSHAY ID: _ _ - _ _ _ - _ - C - _ _- _ _ _ _ _RNTCP TB Reg No. __________________ Or
☐ Not Applicable
State: _____________________ District:_______________ Tuberculosis Unit (TU): _________________
Drug Susceptibility Test (DST) results
Lab Sr.No1st line drugs SLI FQ Other
R H
(inhA
)
H
(kat
G)
S E Z Km
Cm
Am
Lfx
Mfx
(0
.5)
Mfx
(2
)
Eto
PA
S
Lzd
Cfz
Clr
Azi
Date Result: ______________ Date Reported:_______________ Reported by:________________________ R: Resistant; S: Susceptible; C: Contaminated; -- Not done (Name and Signature)
Other tests for TB diagnosisTest (Please Specify): ______________________Result:__________________________________________________________________________________________________________________________________________________________________________Date reported:_______________ Reported by:_______________________ (Name and Signature)
Cartridge Based Nucleic Acid Amplification Test (CBNAAT)Sample A B M. Tuberculosis Detected Not Detected N/ARif Resistance Detected Not Detected Indeterminate N/A Test No Result Invalid Error – Error Code________ (Please arrange for fresh sample)
Date tested: ______________ Date Reported:_______________ Reported by:_______________________ (Name and Signature)
Culture ( LJ LC)Lab Sr. No Negative Positive NTM (write species) Contamination
Date Result: ______________ Date Reported:_______________ Reported by:_______________________ (Name and Signature)
Line Probe Assay (LPA) Direct Indirect Lab serial ___________
First line LPARpoB: ---- locus control: � present � absent
WT1: �present � absent WT2: � present � absent WT3: � present �absent WT4: � present � absent
WT5: � present � absent WT6: � present �absent WT7 : � present �absent WT8 : � present � absent
MUT1 (D516V): � present �absent MUT2A (H526Y): � present �absent MUT2B (H526D): � present �absent MUT3 (S531L): � present �absent
Kat G: ----- locus control: � present � absent
WT1 (315): � present � absent
MUT1 (S315T1): � present � absent MUT2 (S315T2): � present � absent
Inh A:----- locus control: �present �absent
WT1 (-15, -16): � present � absent WT2 (-8): � present � absent
MUT1 (C15T): � present � absent MUT2 (A16G): � present � absent MUT3A (T8C): � present � absent MUT3B (T8A): � present � absent
Second line LPAgyrA:--
locus control: � present � absent
WT1 (85-90): � present � absent
WT2 (89-93): � present � absent
WT3 (92-97): � present � absent
MUT1 (A90V): � present � absent
MUT2 (S91P): � present � absent
MUT3A (D94A): � present � absent
MUT3B (D94N/Y): � present � absent
MUT3C (D94G): � present � absent
MUT3D (D94H): � present � absent
gyrB:----
locus control: �present �absent
WT1 (536-541): � present � absent
MUT1 (N538D): � present � absent
MUT2 (E540V): � present � absent
rrs:-----
locus control: �present �absent
WT1 (1401-02): � present � absent
WT2 (1484): � present � absent
MUT1 (A1401G): � present � absent
MUT2 (G1484T): � present � absent
eis:-----
locus control: �present �absent
WT1 (37): � present � absent WT2 (14, 12, 10): � present �
absent WT3 (2): � present � absent
MUT1 (C-14T): � present � absent
Final LPA Interpretation: ---
MTB result � MTB positive � MTB Negative RIF � Sensitive � Resistant � Indeterminate INH �Sensitive �Resistant � Indeterminate Quinolone � Sensitive � Resistant � Indeterminate SLID �Sensitive �Resistant � Indeterminate
Date Result: ______________ Date Reported:_______________ Reported by:________________________ (Name and Signature)
REFERRAL SLIP (Referring health facility copy)
Date: …………Lab referred to:….………………..Name of referring HF: ………………………………..Name of Patient: ………………………………………….. Age: ……… years Sex: M / F / TGAddress of patient (with landmarks)
……………………………………………………………………..
……………………………………………………………………
……………………………………………………………………Patient’s / Contact person’s Mobile number : __________________________________Kindly tick
Cough……………………..daysFever……………………..daysLoss of weight ……………………..daysNight sweat ……………………..daysBlood in sputum/ cough ………………days
Contact of TB / MDR TB
Stamp of HF Referred by (Name & Sign)
REFERRAL SLIP(Patient copy)
Date: …………Lab referred to:….………………..Name of referring HF: ………………………………..Name of Patient: ………………………………………….. Age: ……… years Sex: M / F / TGAddress of patient (with landmarks)
……………………………………………………………………..
……………………………………………………………………
……………………………………………………………………Patient’s / Contact person’s Mobile number : __________________________________Kindly tick
Cough……………………..daysFever……………………..daysLoss of weight ……………………..daysNight sweat ……………………..daysBlood in sputum/ cough ………………days
Contact of TB / MDR TB
Stamp of HF Referred by (Name & Sign)
REFERRAL SLIP(Lab Copy)
Date: …………Lab referred to:….………………..Name of referring HF: ………………………………..Name of Patient: ………………………………………….. Age: ……… years Sex: M / F / TGAddress of patient (with landmarks)
……………………………………………………………………..
……………………………………………………………………
……………………………………………………………………Patient’s / Contact person’s Mobile number : __________________________________Kindly tick
Cough……………………..daysFever……………………..daysLoss of weight ……………………..daysNight sweat ……………………..daysBlood in sputum/ cough ………………days
Contact of TB / MDR TB
Stamp of HF Referred by (Name & Sign)
SR No. _____ ____________
SR No. _____ ____________
SR No. _____ ___________
NIKSHAY ID. _____ ____________ NIKSHAY ID. _____ ____________ NIKSHAY ID. _____ ____________
REVISED NATIONAL TUBERCULOSIS CONTROL PROGRAMMETreatment Card TB Notification No / NIKSHAY ID ______________
State:______________________ City / District: ___________ TB Unit:_____________ PHI: _____________ Area: Tribal / Rural / Urban / Urban slum
Name: ______________________Sex: M F TG Age: ____ Marital status: _______ Occupation:_____________ Socioeconomic status: APL/ BPLComplete Address: House No. _______ Road: ___________ Important landmark: __________________ Ward/Village: __________ Town/City: _______ Taluka/Mandal:______Pin code: ______ Mobile:__________ Aadhaar No.: _______ Key population: Contacts / Miners / Refugees / Migrants / Prison inmatesName and Address of contact person ______________________________________________________ Mobile No. __________________________
Name of Treatment Supporter _________________________________________Designation ______________Mobile No.: _________________________Initial home visit by _______________ Date________ Type of Treatment Adherence – DOT / Family DOT / ICT supported, specify _______ / Other ______Predominant symptom _________ Duration _________day Number of health care providers visited before diagnosis for current episode: ________
H/O of Previous ATT: ___ months of treatment ___ months since end of last episodeSource of treatment: Public Private Previous regimen: _____________
Initial weight of patient: _____ kg height _____ cm
<6yrs >6yrs No of children less than 6 years given chemoprophylaxis = _____
No. of household contacts
Name Wt(Kg)
Dose(mg)
1 2 3 4 5 6
No. screenedNo. with symptoms No. evaluatedNo. diagnosed No. put on treatment
Addiction related information Current Tobacco user Yes NoIf yes, Smoking Smokeless Linked for cessation Yes NoIf tobacco user, status of tobacco use at end of treatment Quit Not quitH/o Alcohol intake Yes NoIf yes, linked for deaddiction Yes No
Investigations(ZN / FM / CBNAAT/ Liquid C / Solid C)
Date LabLab. No.
Test result
Sample sent to CDST
(date)
DSTresult
Pre-treatment
End of Intensive Phase
End of treatment
Site of disease
Pulmonary Extra PulmonarySite ______________
Type of Patient New Recurrent Transferred in Treatment After Failure Treatment after Others, previously lost to followup treated (Specify)_____
Case Definition Microbiologically confirmed Clinically diagnosed TB
HIV related information
HIV Status: Unknown Reactive NR Date_____ PID_____
CPT delivered on: (1) (2) (3) (4) (5) (6)
Initiated on ART: No Yes Date & ART No._____
Diabetes related information
Diabetes Status: Unknown Diabetic Non-Diabetic
RBS_____ FBS_____ End IP____ End treatment____
Initiated on ADT: No Yes Date & ADT No._____
Other co-morbidityDetails ___________________________________________
Signature of MO with date _____________________
Other investigations (if any) with date and result
Regimen – New / Previously Treated Date of initiation of intensive phase _________ Date of initiation of continuation phase ____________Dosage frequency Daily Intermittent Drug formulations FDC Combipack Loose drugs Drug packaging PWB Strips
Weight Band: Adult: 25-39 Kg 40-54 Kg 55-69 Kg ≥70 Kg Pediatric: 4-7 Kg 8-11 Kg 12-15 Kg 16-24 Kg 25-29 Kg 30-39 Kg
Dosages: FDC / Combipack ______ per day Weight _________ (kg) Height_________ (cm)
Mark when doses are taken under direct observation, when the dose was not observed, O when missed the doseRecord CP from fresh lineMonth/year
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Wt
Retrieval Actions for Missed Dose Details of Adverse events
DateBy
WhomWhom
contacted
Reason for missed doses
Outcome of retrieval action
Date of adverse
event
Details of symptoms
Action takenDuration of
management for adverse event
Outcome of adverse event
Post treatment follow up clinical & sputum (Results with date)Follow up Clinical CXR Smear Culture Impression6 mths of Rx12 mths of Rx18 mths of Rx24 mths of Rx
Treatment outcome with date: ______________ Signature of the MO with date: _____________
Loose drugs
DosePills
H R Z E S
Remarks______________________________________________________________________________________________________________________
Nutrition support (if any, give details)
RNTCP TB identity card
Name: __________________________________________________________
Sex M F TG Age:____________
Address:_________________________________________________________
________________________________________________________________
Contact No: _________________ Aadhar ID. ___________________________
PHI __________ TU _____________ District __________
NIKSHAY ID:__________________________
Name and designation of treatment
supporter:_____________________________
_____________________________________
Contact number and address of treatment
supporter:-____________________________
_____________________________________
CPT ART Diabetic Smoker
Date of starting treatment: (DD/MM/YYYY)
Site of Disease
Pulmonary
Extra pulmonary
Case Definition
Microbiologically confirmed
Clinically diagnosed
Treatment regimen:
New
Previously treated
Type of Patient
New
Recurrent
Treatment after Lost to
Follow up
Treatment after Failure
Other Previously treated
Transferred in
Weight Band:
Adult: 25-39 Kg 40-54 Kg 55-69 Kg ≥70 Kg
Pediatric: 4-7 Kg 8-11 Kg 12-15 Kg 16-24 Kg 25-29 Kg 30-39 Kg
Sputum results
Smear Date Smear Result Culture Date Culture Result
Diagnosis
End IP
End RX
6 months
12 months
18 months
24 months
Appointment dates
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________In case of side effects or queries please contact
Name and contact number:______________________________________ __________________________________________________________
Treatment outcome: _________________________ Date:____________
RNTCP PMDT Treatment Book
Patient’s name: _____________________________________________
Age: _______yrs Gender: Male Female Transgender
Address: __________________________________________________
_________________________________________________________
Marital status: ______________ Occupation: ____________________
Contact No: _______________________________________________
Aadhar ID ________________________________________________
Name, designation of treatment supporter:_________________________
__________________________________________________________
_________________________________ Contact no:_______________
State:__________________ District: ___________________________
TB Unit: ________________ PHI:_____________________________
Initial home visit: Date _______________ By:_____________________
DR TB Centre:____________ District __________ State ___________
NIKSHAY ID CDL NIKSHAY ID PMDT NIKSHAY ID PMDT TB No
Reason for Testing
New Previously Treated
Presumptive TB Private Referral Presumptive NTM
Presumptive
MDR TB
At diagnosis
Contact of MDR/RR TB
Follow up Sm+ve at end IP
Private referral
Presumptive H mono/poly
Presumptive
XDR TB
MDR/RR TB at diagnosis
4 months culture positive
3 monthly, for persistent culture positives (treatment month __)
Culture reversion
Failure of MDR/RR-TB regimen
Recurrent case of second line treatment
Drug Susceptibility Test (DST) results
Date of sample collection R H
(in
hA
)H
(ka
tG)
S E Z Km
Cm
Am
Lfx
Mfx
(0.
5)
Mfx
(2)
Eto
*P
AS
*Lz
dC
fz*
Clr*
Azi
*B
dq*
Dlm
*
R: Resistant; S: Susceptible; C: Contaminated; -- Not done *whenever available
Contact Investigation
No of members screened
No of presumptive TB cases identified
No of presumptive TB cases evaluated
No diagnosed with TB
No of DR-TB diagnosed
DR-TB Centre Committee meetings – dates and decisions
Date Decision Duration of indoor stay
TB Site: Pulmonary Extra Pulmonary
If extra pulmonary, please specify ____________________
Treatment regimen
Regimen for INH mono/poly resistant TB Regimen for MDR/RR TB Shorter Regimen Modified Regimen for MDR/RR-TB + FQ/SLI resistance Regimen for XDR TB Modified Regimen for mixed pattern resistance Regimen with New Drug for MDR-TB Regimen + FQ/SLI resistance Regimen with New Drug for XDR-TB Regimen with New Drug for failures of regimen for MDR-TB Regimen with New Drug for failures of regimen for XDR-TB Regimen with New Drug for mixed pattern resistance
Initiation Date: __________________ Registration Date: _______________
Initial Weight: ________kgs Height:_________cms
Weight band:
Conventional - <16 Kg 16-25 Kg 26-45 Kg 46-70 Kg >70 Kg
Shorter regimen - <30 Kg 30-50 Kg >50 Kg
Drug and DosagesDrugs Dose (mg)HREZKmAmCmLfxMfxCsEtoPASLzdCfzAmx ClvClrBDQ
Patient eligible and consented for New Drug* Yes No
If No, reason________________________________________________________
Name & Signature of Treating Physician:
______________________________________________
*Whenever available
Month of
Treatment
Culture Results Other Investigations
Date Lab No Culture S. Cr LFT ECG*-QTC
Interval
CBC/
Platelets
Electrolyte (K,
Mg, Ca)
Urine
Gravindex
Diagnosis
1st
week
2nd
week
3rd
week
4th
week
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
* ECG to be done daily (first two weeks), weekly (for 3 months) then monthly
Drug Susceptibility Testing (DST) Results
Drug
Date of specimen collection & type of DST (LJ/LC/LPA/CBNAAT)
Month___ Month___ Month___ Month___ Month___ Month___
R
H
(inhA)
H2
(katG)
S
E
Z
Km
Cm
Am
Lfx
Mfx
(0.5)
Mfx
(2.0)
Eto
PAS
Lzd
Cfz
Patient’s Name:_________________________
Blood Sugar Testing:
Date:___________
RBS:__________
FBS:____________
ADT*
(*write date of starting)
Thyroid Function Test
Month Zero Six
Date
T3
T4
TSH
Date of starting intensive phase: ______________________
Date of starting continuation phase:______________________
Details of change
Date Changed regimen Reason for change
ADMINISTRATION OF DRUGS (one line per month)
Month
& Yr
Day Wt
in
Kg1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Mark in the boxes: = directly observed; Unsupervised; = drugs not taken; X = initiation of new box;
Recording of CP should start from fresh line.
Month
& Yr
Day Wt
in
Kg1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Mark in the boxes: = directly observed; Unsupervised; = drugs not taken; X = initiation of new box;
Recording of CP should start from fresh line.
Month
& Yr
Day Wt
in
Kg1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Mark in the boxes: = directly observed; Unsupervised; = drugs not taken; X = initiation of new box;
Recording of CP should start from fresh line.
Month
& Yr
Day Wt
in
Kg1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Mark in the boxes: = directly observed; Unsupervised; = drugs not taken; X = initiation of new box;
Recording of CP should start from fresh line.
Date of
retrieval
action
By whom
Who
contacted
Reason for
missed doses
Outcome of retrieval
action
Date of
adverse drug
reaction
Details of symptoms Action taken
Clinical Notes
Date of visit:
Chief Complaints:
Clinical examination (major findings) :
Counselling notes:
Weight
Investigations
Treatment
Clinical Notes
Date of visit:
Chief Complaints:
Clinical examination (major findings) :
Counselling notes:
Weight
Investigations
Treatment
Clinical Notes
Date of visit:
Chief Complaints:
Clinical examination (major findings) :
Counselling notes:
Weight
Investigations
Treatment
Clinical Notes
Date of visit:
Chief Complaints:
Clinical examination (major findings) :
Counselling notes:
Weight
Investigations
Treatment
Clinical Notes
Date of visit:
Chief Complaints:
Clinical examination (major findings) :
Counselling notes:
Weight
Investigations
Treatment
Clinical Notes
Date of visit:
Chief Complaints:
Clinical examination (major findings) :
Counselling notes:
Weight
Investigations
Treatment
Treatment outcome Date Remarks
Cured
Treatment completed
Died
Failed – Culture non conversion
Failed – Culture reversion
Failed – Additional drug resistance
Failed – Adverse Drug Reaction
Lost to follow up
Regimen Change
Not evaluated
In remarks column, provide cause of death, reason for lost to follow up, latest TB
no. in case of failure and put on treatment further
Post treatment follow up clinical & sputum (Result with date)Follow up Clinical Smear Culture CXR Impression
6 months of Rx
12 months of Rx
18 months of Rx
24 months of RX
REVISED NATIONAL TUBERCULOSIS CONTROL PROGRAMME Referral / Transfer form for treatment Serial Number
To be filled in triplicate. One copy to be sent to the DTO receiving the patient, one copy to the health facility where the patient is referred to, and one copy to the patient
Name and address of referring health facility ___________________________________________________
Contact Number and e-mail address of referring health facility: ___________________________________
Name and address of health facility to which patient is referred ___________________________________ __________________________________________________________________________________________
Name of patient__________________ Age________________ Sex M F TG
Complete Address__________________________________________________________________________
_________________________________________________________ Contact no. ____________________
Patient detail
Site of disease
Pulmonary Extra Pulmonary, Site ______________
Type of Patient New Recurrent Transferred in Treatment After Failure Treatment After Others, previously treated Lost to Follow-up (Specify)________
Case DefinitionMicrobiologically confirmed Clinically diagnosed
H/O of ATT: ___ months of treatment
___ months since end of last episode
Diagnosis detailsDate of diagnosis: __/__/___ Name of laboratory: Type of test: ZN / FM / CBNAAT / CultureResult : TB notification number:
HIV Status: R NR UnknownDST Status: Rif Sensitive Rif Resistant Unknown, if unknownSample sent for DST to ______________Date: __/__/__
Treatment regimen: New Previously Treated
Date of treatment initiation: : __/__/__ Number of doses:_____________________
Referred for: Initiation of treatment
Adverse drug reaction (give details) ____________________________________________
Transfer out (give details)____________________________________________________
Any other (give details)______________________________________________________
Name and designation of the referring doctor_______________________________________________
Date referred
-------------------------------------------------------------------------------------------------------------------------- Serial Number____________________________
For use by the health facility where the patient has been referred
Name of receiving health facility___________________ Name of TB Unit and District__________________
Name of patient __________________ TB No (if available) ________________________
Age__________ Sex M F TG Date of receipt of patient______________________
Date of initiation of treatment _____________________ Treatment regimen __________________________
Result of End IP specimen examination _____________ Date of end IP specimen examination ___________
Treatment outcome ______________________ Date of treatment outcome ____________________
Signature Designation _____
Date___________________________________
This portion of the form has to be sent back to the referring unit as soon as the patient has been initiated on RNTCP treatment
RNTCP PMDT Treatment Register
Month ________Quarter ________ Year ___________ District: ________________ C-DST Lab: ____________ DR-TB Centre:_______________ State: _______
PM
DT
TB
No
NIK
SH
AY
ID
PM
DT
NIK
SH
AY
ID
CD
L N
IKS
HA
Y ID Patient’s
name in full
Gen
der
(M/F
/TG
)
Age
in y
rs
Complete address & mobile number
Name of health
facility, TU, district
@ R
eas
on f
or T
estin
g
Site
of
Dis
ease
(P
/EP
) Type (New,
Recurrent, TALFU, Failure, Others)
DST Details
Typ
e (L
J/LC
/ LP
A/
CB
NA
AT
)
Dat
e of
DS
T
Results
R H(in
hA
)
H(k
atG
)
S E Z Km
Cm
Am
Lfx
Mfx
(0.
5)
Mfx
(2)
Eto
PA
S
Lzd
Cfz
@ Presumptive TB – 1; Private referral – 2; Presumptive NTM – 3;
@ Presumptive MDR TB, At diagnosis–4; Contact of MDR/RR TB – 5; Follow up Sm +ve at end IP – 6; private referral – 7; Discordance resolution – 8; Presumptive H mono/poly – 9; MDR/RR TB at diagnosis – 10; ≥ 4 months culture positive –11; 3-monthly for persistent culture positives –12; Culture reversion –13: Failure of MDR/RR-TB regimen –14; Recurrent case of second line treatment –15
Typ
e of
DR
TB
Pat
ient
RR
TB
/MD
RT
B/X
DR
T
B
DR
TB
Reg
ime
n #
Dat
e of
Tre
atm
ent i
nitia
tion
Culture and DST Results at initiation and during DR TB Treatment (Treatment months) TB/HIV Collaborative activities
Fin
al T
reat
men
t Out
com
e
Post treatment follow up
Rem
arks
0 3 4 5 6 7 9 12 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36
Dat
e of
Tes
t
PID
No
HIV
Sta
tus
Dat
e of
CP
T in
itiat
ion
Dat
e of
AR
T in
itiat
ion
6 m
12m
18m
24m
dd/m
m/y
y dd/m
m/y
y dd/m
m/y
y dd/m
m/y
y dd/m
m/y
y dd/m
m/y
y dd/m
m/y
y dd/m
m/y
y dd/m
m/y
y dd/m
m/y
y dd/m
m/y
y dd/m
m/y
y dd/m
m/y
y dd/m
m/y
y dd/m
m/y
y dd/m
m/y
y dd/m
m/y
y dd/m
m/y
y dd/m
m/y
y dd/m
m/y
y dd/m
m/y
y dd/m
m/y
y dd/m
m/y
y dd/m
m/y
y dd/m
m/y
y dd/m
m/y
y dd/m
m/y
y dd/m
m/y
y dd/m
m/y
y dd/m
m/y
y Clin
ical
Clin
ical
Clin
ical
Clin
ical
Cul
ture
Cul
ture
Cul
ture
Cul
ture
Cul
ture
Cul
ture
Cul
ture
Cul
ture
Cul
ture
Cul
ture
Cul
ture
Cul
ture
Cul
ture
Cul
ture
Cul
ture
Cul
ture
Cul
ture
Cul
ture
Cul
ture
Cul
ture
Cul
ture
Cul
ture
Cul
ture
Cul
ture
Cul
ture
Cul
ture
Cul
ture
Cul
ture
Cul
ture
Cul
ture
Spu
tum
Spu
tum
Spu
tum
Spu
tum
# Cases put on: Regimen for H mono/poly resistant TB – 1; Regimen for MDR/RR TB – 2; Regimen for MDR/RR-TB + FQ/SLI resistance – 3; Regimen for XDR-TB – 4; Regimen with Bedaquiline for MDR-TB + FQ/SLI resistance – 5; Regimen with Bedaquiline for XDR-TB – 6; Regimen with Bedaquiline for failures of regimen for MDR-TB + FQ/SLI resistance – 7; Regimen with Bedaquiline for failures of regimen for XDR-TB – 8; Regimen with Bedaquiline for mixed pattern resistance – 9
1
Revised National Tuberculosis Control Programme – TB Notification Register Year ___________ PHI_________ Health Facility ID ___________
TB
not
ific
atio
n n
o.
(NIK
SHA
Y)
Name (in full)
Age
Sex
(M
/F/T
G)
Complete Address(including district /
state)
Pin
cod
e
Mob
ile
/L
and
lin
eN
um
ber
Aad
haa
r N
o.
Key
pop
ulat
ion
*
Typ
e of
pat
ien
t**
Sit
e (
P/E
P)
Cas
e D
efin
itio
n£ Microbiological confirmation test
resultsResults of
Other tests (X-
Ray/Histopatho/ FNAC/
Clinical/ /Other, specify)
HIV
Sta
tus±
Dia
bet
esS
tatu
s^
Dat
e of
sam
ple
sen
t fo
r D
ST
(N
O if
not
sen
t, N
A if
no
t app
lica
ble)
Res
ult
of
DS
T@ Status of
treatment***
Health facility for treatment (Details)
Dat
e of
init
iati
on o
f tr
eatm
ent
Date Lab Name
Lab no.
Test¥
Res
ult
s of
Tes
t#
………………… ………………………
………………… ………………………
………………… ………………………
………………… ………………………
………………… ………………………
………………… ………………………
………………… ………………………
*Key population1. Contact of TB/DRTB case, 2. Tobacco, 3. Prison inmates, 4. Miner, 5. Migrant, 6. Refugee, 7. Urban slum, 8. Health-care worker, 9. Other (specify)
** Type of patient (use complete words)New, Recurrent, Treatment after Failure, Treatment after Lost to Follow up, Other Previously Treated, Transferred in
£ Case DefinitionMicrobiologically Confirmed, Clinically Diagnosed
¥ Test ZN, FM, Culture, CBNAAT
# Result of testFor Smear result – Grades for smear positive (Scanty with no. of bacilli, +1, +2, +3), NEG for smear negativeFor GX result – MTB detected Rif Resistance, MTB detected Rif sensitive, MTB detected Rif Indeterminate, MTB not detected, Error, Invalid, No resultFor Culture result – Grades for culture positive, NEG for culture negative
± HIV StatusHIV status as reported before or during TB treatment R – Reactive, NR – Non-Reactive, U – Unknown.
^Diabetes Status D=Diabetes, N=NonDiabetes, U = Unknown
@ Sensitive= if sensitive to tested drugs, Name of drug if resistant to any – R= Rifampicin, H=Isoniazide, E=Ethambutol, Z=Pyrazinamide, Sm=Streptomycin Lx=Levofloxacin, Mx=Moxifloxacin, Km=Kanamycin, Cm=Capreomycin
***Status of treatment-1. Initiated on First line treatment in the same Health Facility2. Initiated on treatment outside Health Facility 3. Initiated on second line treatment 4. Treatment initiated outside RNTCP5. Incomplete/ incorrect address6. Died7. Migrated & untraceable8. Refuse for treatment9. Repeat diagnosis10. Patient already on treatment/ Follow up patient11. Wrong diagnosis12. Referred for treatment with pending feedback13. Other
2
Revised National Tuberculosis Control Programme – TB Notification Register Year ___________ PHI__________ Health Facility ID ___________
Typ
e of
reg
imen
(N
/ P
T /
Ou
tsid
e R
NT
CP
)
Wei
ght
at b
egin
nin
g of
tre
atm
ent
Dos
age
Fre
qu
ency
(D
aily
/ In
term
itte
nt) Follow-up smear examinations
Treatment Outcome#
If HIV-Reactive
Post treatment follow up
End of IP End of Treatment ExamAt 6 monthsDate______
At 12 months Date______
At 18 monthsDate______
At 24 monthsDate______
Treatment supporter details
Remarks
DateDMC Name
Smear result
Date of sample
collected for DST
Result of
DST@Date
DMC Name
Smear results
Date of sample collecte
d for DST
Resultof
DST@Outcome Date
CPT (y/n) date
ART (y/n) date
Sym
pto
ms
* CX
R
Sm
ear
Cu
ltu
re
Sym
pto
ms
CX
R
Sm
ear
Cu
ltu
re
Sym
pto
ms
CX
R
Sm
ear
Cu
ltu
re
Sym
pto
ms
CX
R
Sm
ear
Cu
ltu
re
Name Designation
# Treatment Outcome –Cured, Treatment Completed, Died, Lost to follow up, Failure, Not evaluated or Treatment change
± Additional treatments if patient HIV-ReactiveRequired only for patients known to be HIV Reactive. If provided by any source during TB treatment, enter “Y” and approximate date. If not provided / unknown, enter “N”.*Symptoms- Mention predominant system- Cough-C, Fever-F, Haemoptysis-H, Weight loss-W, Night Sweat - N Others-O, No symptoms - NS
Lab.
Ser
ial N
o. Date of collection
of first specimen
Name (in full)
Age
Sex
M/ F
/TG
Complete address (for diagnosis
patients) & Phone No.
Key Population1
Name and type of
referring health facility2
Reasons for Examination
Presumptive TB / RE /
Presumptive NTM
Predominant symptom3 & its duration4
History of >1 month
ATT (Yes/No)
Follow-up
Nikshay ID
Regimen New (N) / Previously
Treated(PT)
Month
Post Treatment follow up
month
1 Key population – 1. Contact of TB/DRTB case, 2. Tobacco, 3. Prison inmates, 4. Miner, 5. Migrant, 6. Refugee, 7. Urban slum, 8. Health-care worker, 9. Other (specify) 2 Name of referring health facility-PHI/DMC/TB/DTC/ICTC/ART/Medical College/DR-TB centre / Private/ Others, specify3Predominant symptoms: Cough-C, Fever-F, Haemoptysis-H, Weight loss-W, Night Sweat - N Others-O, No symptoms - NS4Duration of predominant symptoms should be recorded in days
TB Laboratory Register
Type of specimen
Visual appearance5 Results
Date of Result
HIV status (Reactive/
Non Reactive/ Unknown)
Diabetic status
(Diabetic/ Non
Diabetic/ Unknown)
Sample for DST
sent (Y/N) with date
DST result7 (write the drugs to which resistance is
demonstrated)
NIKSHAY ID (notification
no.)
Treatment initiation details
(TB No. & TU details) / Referral for
treatment
Signature Remarks8
a6 b6 a6 b6
5Visual appearance- mention M, B, or S., Mucopurulent, Blood stained or Saliva6a- stands for supervised spot sample, b- stands for early morning sample7 Sensitive= if sensitive to tested drugs, Name of drug if resistant to any – R= Rifampicin, H=Isoniazide, E=Ethambutol, Z=Pyrazinamide, SM=Streptomycin Lx=Levofloxacin, Mx (0.5) or (2) =Moxifloxacin, Km=Kanamycin, Cm=Capreomycin, Am=Amikacin, Eto=Ethionamide, Lzd=Linezolid, Cfz=Clofazimine8 Remarks column can include date of starting treatment, treatment regimen, TB no., referral details with date, remarks on un blinded rechecking, etc.
RNTCP Laboratory Register for culture, CBNAAT and drug susceptibility testing
S No
NIKSHAY ID
Patient’s full name(Address/contact
details)Age
Ge
nd
er
(M/F
/TG
)
Key Population1
Name and type (PHI / DMC / TU/ DTC /
ICTC / ART / Medical College / DR-TB Centre
/ Private Others, specify)
of referring health facility
Reason for testing Date
Ty
pe
(S
pu
tum
/oth
er-
sp
ec
ify
)
Sp
ec
imen
co
nd
itio
n #
(M
/B/S
/C)
C&
DS
T L
ab
Mic
ros
co
py
R
es
ult
Diagnosis/DST Follow up
Sp
ec
imen
co
llec
tio
n
Sp
ec
imen
sen
t to
lab
Sp
ec
imen
re
cei
pt
at
lab
ora
tory
New/ PT
@
Pre
dom
inan
t sy
mpt
om2
and
dura
tion3
PMDT TB No
Month of FU
@ Presumptive TB – 1; Private referral – 2; Presumptive NTM – 3;
@ Presumptive MDR TB, At diagnosis–4; Contact of MDR/RR TB – 5; Follow up Sm +ve at end IP – 6; private referral – 7; Discordance resolution – 8; Presumptive H mono/poly – 9; MDR/RR TB at diagnosis – 10; ≥ 4 months culture positive –11; 3-monthly for persistent culture positives –12; Culture reversion –13: Failure of MDR/RR-TB regimen –14; Recurrent case of second line treatment –
# M–Mucopurulent; B– Blood stained; S– Saliva; C– Contaminated
1 Key population – 1. Contact of TB/DRTB case, 2. Tobacco, 3. Prison inmates, 4. Miner, 5. Migrant, 6. Refugee, 7. Urban slum, 8. Health-care worker, 9. Other (specify) 2Predominant symptoms: Cough-C, Fever-F, Haemoptysis-H, Weight loss-W, Night Sweat - N Others-O, No symptoms - NS3Duration of predominant symptoms should be recorded in days
RNTCP Laboratory Register for Culture, CBNAAT and Drug Susceptibility Testing
Rapid DST ResultsCulture Results
Standard DST Results (R/S) Reporting of results
Te
st
pe
rfo
rme
d
(LP
A/C
BN
AA
T)
Da
te o
f re
ceip
t &
CD
L
NIK
SH
AY
ID
Va
lid
* (Y
/N)
TB
† (
Y/N
)
RIF
‡
(
R /
S /
I /
N A
)
INH
(in
hA
)(R
/S/N
A)
INH
(K
atG
)(R
/S/N
A)
Ty
pe
(L
J/L
C)
CD
L N
IKS
HA
Y I
D
Re
su
lts
§
Ty
pe
(L
J/L
C)
Da
te o
f re
ceip
t &
CD
L
NIK
SH
AY
ID
Rif
am
pic
in
Iso
nia
zid
(0
.1)
Iso
nia
zid
(0
.4)
Str
ep
tom
yci
n
Eth
am
bu
tol
Py
razi
nam
ide
Ka
na
my
cin
Ca
pre
om
yci
n
Am
ika
cin
Le
vo
flo
xa
cin
Mo
xif
lox
aci
n (
0.5
)
Mo
xif
lox
aci
n (
2.0
)
Eth
ion
am
ide
PA
S
Lin
ezo
lid
Clo
fazi
min
e
Oth
er
__
___
__
___
___
Oth
er
__
___
__
___
__
Oth
er
__
___
__
___
__
Da
te o
f re
po
rtin
g
cu
ltu
re r
esu
lt
Da
te o
f re
po
rtin
g D
ST
re
su
lt
Re
ma
rks
* Valid = Y if both Amplification Control (AC) band & Conjugate Control (CC) band present; if either are missing, record N, and record no additional LPA results for this specimen.
† TB = Y if M. tuberculosis (TUB) band on LPA strip confirming identity as M. Tb or MTB Detected in CBNAAT, N if no TUB band on LPA strip or MTB Not Detected in CBNAAT
‡ R = Resistant, S = Sensitive, I = Indeterminate, NA = no result, judged by no locus control band on LPA strip for rpo-B (RIF), or for inh-A or kat-G (INH) or for gyr-A or gyr-B for FLQ or eis for ETH, or rrs for SLI. In case of CBNAAT, specify for NA, i.e. Error, Invalid, No Result
§ Negative = no growth, Conta = contaminated, NTM = Non-Tuberculosis Mycobacteria/fast grower, 3+ = confluent growth, 2+ = >100 colonies, 1+ = 10–100 colonies; Sc# Scanty <10 . Positive culture results should only be reported after identity for M. tuberculosis is confirmed with PNB, Niacin, Catalase, Rapid Immunoassay, or other methods.