revised tb recording and reporting forms and registers - version 2006
TRANSCRIPT
WHO/HTM/TB/2006.373
Revised TB recording and reporting forms and registers – version 2006
Prepared by the Expert Group on TB Recording and Reporting forms and registers WHO Stop TB Department, Geneva, September 2006
© World Health Organization 2006 All rights reserved. The designations employed and the presentation of the material in this publicationimply the expression of any opinion whatsoever on the part of the World Health Orga
do not nization
concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either express or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. The named authors alone are responsible for the views expressed in this publication.
2
Writing group Kayla Laserson, United States Centers for Disease Control and Prevention (CDC), René L’Herminez, KNCV Tuberculosis Foundation (KNCV), Pierre-Yves Norval, Coordinator of the Expert Group on Recording and Reporting, World Health Organization (WHO) Stop TB Department (STB), Arnaud Trébucq, International Union Against Tuberculosis and Lung Disease (The Union). Expert Group on TB Recording and Reporting Einar Heldal (WHO Consultant), Kayla Laserson (CDC), René L’Herminez (KNCV), Michael Rich (WHO Consultant), Arnaud Trébucq (The Union). Jeong Ym Bai (Ministry of Health, South Korea), Mao Tan Eang (Ministry of Health, Cambodia), Rober Gie (Stop TB Partnership Childhood TB subgroup), Vahur Hollo (Ministry of Health, Estonia), Chris Seebregts (Medical Research Council, South Africa). Sergio Arias, Mirtha Del Granado (WHO Regional Office for the Americas), Samiha Bagdadhi, Ridha Djebeniani (WHO Regional Office for the Eastern Mediterranean), Philippe Glaziou, Pieter van Maaren (WHO Regional Office for the Western Pacific), Suvanand Sahu (WHO Regional Office for South-East Asia), Jerod Scholten (WHO Regional Office for Europe), Oumou Bah-Sow (WHO Regional Office for Africa), Fabienne Jouberton, Robert Matiru (Stop TB Partnership, Global Drug Facility). Mohamed Aziz, Léopold Blanc, Daniel Bleed, Karin Bergström, Knut Lönnroth, Malgosia Grzemska, Mehran Hosseini, Pierre-Yves Norval (Coordinator of the Expert Group on Recording and Reporting), Paul Nunn, Alasdair Reid, Brian Williams (STB). Christopher Tantillo, Philippe Veltsos (WHO Department of Information Technology and Telecommunications). Acknowledgements In addition to review by the WHO Strategic and Technical Advisory Group for TB, the following people reviewed the forms and provided valuable comments: Avijit Choudhury, William Coggin, Amal Galal, Wieslaw Jakuboviak, John Mansoer, Anna Nakanwagi-Mukwaya, Patricia Whitesell Shirey, Kelly Stinson, Douglas Fraser Wares, and the 105 countries who responded to the WHO field test survey.
3
Table of contents
1. RATIONALE AND PROCESS OF THE REVISION............................................................................................. 5
1.1 AIM OF THE REVISION ...................................................................................................................... 5 1.2 PROCESS OF THE REVISION............................................................................................................... 5 1.3 PRESENTATION OF THE REVISION.................................................................................................... 6 1.4 NEXT STEPS..................................................................................................................................... 6
1.4.1 STAG ENDORSMENT ............................................................................................................ 6 1.4.2 DISSEMINATION AND IMPLEMENTATION OF THE REVISED FORMS AND REGISTERS................ 6 1.4.3 ELECTRONIC R&R................................................................................................................ 7
2. PART I: ESSENTIAL TB DATA.............................................................................................................................. 8
2.1 REQUEST FOR SPUTUM SMEAR MICROSCOPY EXAMINATION, FORM 1 .............................................. 9 2.2 TB LABORATORY REGISTER, FORM 2............................................................................................. 11 2.3 TB TREATMENT CARD, FORM 3 ..................................................................................................... 13 2.4 TB IDENTITY CARD, FORM 4 ......................................................................................................... 16 2.5 BMU TB REGISTER, FORM 5 ......................................................................................................... 18 2.6 QUARTERLY REPORT ON TB CASE REGISTRATION IN BMU, FORM 6 ............................................. 21 2.7 QUARTERLY REPORT ON TB TREATMENT OUTCOMES AND TB/HIV ACTIVITIES IN BMU, FORM 7 ............................................................................................................................... 23 2.8 QUARTERLY ORDER FORM FOR TB DRUGS, FORMS 8, 8A, 8B ........................................................ 25 2.9 QUARTERLY ORDER FORM FOR LABORATORY SUPPLIES IN BMU, FORM 9..................................... 29 2.10 YEARLY REPORT ON PROGRAMME MANAGEMENT IN BMU, FORM 10 ........................................... 31 2.11 TB TREATMENT REFERRAL/TRANSFER, FORM 11........................................................................... 34
3. PART II: ESSENTIAL TB DATA IN BMU USING ROUTINE CULTURE..................................................... 36 3.1 REQUEST FOR SPUTUM SMEAR MICROSCOPY EXAMINATION, CULTURE, DST, FORM I..................... 38 3.2 TB LABORATORY REGISTER FOR CULTURE, FORM II...................................................................... 39 3.3 TB TREATMENT CARD, FORM III ................................................................................................... 41 3.4 TB IDENTITY CARD, FORM IV....................................................................................................... 43 3.5 TB REGISTER IN BMU USING ROUTINE CULTURE AND DST, FORM V ............................................. 44 3.6 QUARTERLY REPORT ON TB CASE REGISTRATION IN BMU USING ROUTINE CULTURE, FORM VI .. 46 3.7 QUARTERLY REPORT ON TB TREATMENT OUTCOMES AND TB/HIV ACTIVITIES IN BMU USING ROUTINE CULTURE, FORM VII............................................................................................. 47 3.8 QUARTERLY ORDER FORM FOR CULTURE AND DST LABORATORY SUPPLIES IN BMU, FORM VIII.. 48
4. PART III: ADDITIONAL TB DATA..................................................................................................................... 49 4.1 REGISTER OF TB SUSPECTS, FORM A.............................................................................................. 50 4.2 TB LABORATORY REGISTER, FORM B............................................................................................ 51 4.3 TB TREATMENT CARD, FORM C..................................................................................................... 51 4.4 BMU TB REGISTER, FORM D ......................................................................................................... 51 4.5 QUARTERLY REPORT ON TB CASE REGISTRATION IN BMU, FORM E ............................................. 51 4.6 REGISTER OF TB CONTACTS, FORM F ............................................................................................. 52 4.7 QUARTERLY REPORT ON SPUTUM CONVERSION, FORM G............................................................... 53 4.8 QUARTERLY REPORT ON TB TREATMENT OUTCOMES AND TB/HIV ACTIVITIES IN BMU, FORM H............................................................................................................................... 54 4.9 REGISTER OF REFERRED TB CASES, FORM I.................................................................................... 55
ANNEXES: CURRENT TB FORMS AND REGISTERS ........................................................................................ 56 ANNEX 1 REQUEST FOR SPUTUM EXAMINATION .................................................................................. 57 ANNEX 2 REGISTER OF TB SUSPECTS................................................................................................... 58 ANNEX 3 TB LABORATORY REGISTER ................................................................................................. 59 ANNEX 4 TB TREATMENT CARD.......................................................................................................... 60 ANNEX 5 DISTRICT TB REGISTER ........................................................................................................ 62 ANNEX 6 QUARTERLY REPORT ON SPUTUM CONVERSION.................................................................... 64 ANNEX 7 QUARTERLY REPORT ON TB CASE REGISTRATION ................................................................ 65 ANNEX 8 QUARTERLY REPORT ON TB TREATMENT OUTCOMES .......................................................... 66 ANNEX 9 QUARTERLY REPORT ON PROGRAMME MANAGEMENT A, B, C ............................................. 67 ANNEX 10 TB REFERRAL/TRANSFER ..................................................................................................... 71
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1. Rationale and process of the revision
1.1. Aims of the revision
The Stop TB Department (STB) of the World Health Organization (WHO), in collaboration with technical partners, embarked upon a revision of the TB recording and reporting (R&R) system to align the forms and registers to the new Stop TB Strategy. The revision facilitates the monitoring of the 6 components and 18 sub-components of the Stop TB Strategy, which itself was developed to help achieve the Millennium Development Goals. Collection of TB data is part of the general health information system, the aims of which are:
1. To ensure high-quality patient care, a continuum of care, information-sharing with patients
and transfer of information between health facilities. 2. To aid staff in providing adequate services to individual patients. 3. To allow managers at different levels in the national TB control programme
(NTP) to monitor programme performance in a standardized and internationally comparable way.
4. To provide the basis for programmatic and policy development.
1.2. Process of the revision
The revision started in April 2005, as described below. • The Expert Group on the TB Recording and Reporting information system (the Expert
Group), which includes 30 members from the United States Centers for Disease Control and Prevention (CDC), the KNCV Tuberculosis Foundation (KNCV), the International Union Against Tuberculosis and Lung Disease (The Union), six WHO regional offices and selected country NTP managers, met four times (in April, May and September 2005 and June 2006).
• Draft revised forms and registers for field testing and guidelines for field testing were developed between April and September 2005 through exchange and consultation between experts from the main technical partners (WHO, The Union, KNCV, CDC, Global Drug Facility), Stop TB Partnership working groups and subgroups (DOTS expansion, TB/HIV, multidrug-resistant TB (MDR-TB), childhood TB, new TB diagnosis (cf http://www.stoptb.org/wg/tb_hiv/ ), public–private mix, TB and poverty (http://www.stoptb.org/wg/dots_expansion/subgroup_tor.asp ) and countries’ stakeholders.
• These draft revised forms, registers and guidelines were posted in Word format (English and French versions) on the World Wide Web in early November 2005 for country field testing and adaptation.
• Information on the draft forms was shared with the six WHO regional offices and through them with most of the NTP managers.
• The e-mail address to receive comments ([email protected]) was also communicated to countries for comments and information; it was used extensively to respond to a WHO survey of country field testing of the forms and registers (490 messages received).
• A survey on country field testing of the forms and registers was conducted by WHO. Among 105 countries responding to the survey questionnaire, nearly 3/4 (74 countries) had recently revised their forms, 2/3 of them to incorporate collaborative TB/HIV
5
activities; 1/3 of countries used aggregated or individual electronic reporting and recording systems (e-R&R).
• Field testing of the forms and registers was conducted for eight months by countries with participation from technical partners (CDC, KNCV, The Union, WHO) in selected areas.
• A manuscript titled “Revising the Tuberculosis (TB) Recording and Reporting Information System” was offered to the International Journal of Tuberculosis and Lung Disease and is currently under review.
The revised documents presented here are the product of lengthy discussions that have generally resulted in delicate compromises to accommodate a wide variety of wishes and requirements of the different organizations, working groups and individuals.
1.3. Presentation of the revision
The Expert Group developed the revised forms and registers in three complementary parts for country adaptation:
Part I. Essential TB data Part II. Essential TB data in settings using routine culture Part III. Additional TB data
Annexes present the existing WHO-recommended TB forms and registers that were used as the basis for changes. This document is not a guideline. Instead, it focuses on the changes made to the current set of TB recording forms and registers. For convenience, additional or modified data are circled in blue in each set of forms (part I, II, III); removed data are circled in a red dashed line (annexes page 56–71). The rationale for the changes is described below. References to current WHO-recommended forms are from Management of tuberculosis: training for district TB coordinators (WHO/HTM/TB/2005.347a–m) and Management of tuberculosis: training for health facility staff (WHO/CDS/TB/2003.314a–k). References for definitions and TB indicators are from the Compendium of indicators for monitoring and evaluating national tuberculosis programs (WHO/HTM/TB/2004.344) and A guide to monitoring and evaluation for collaborative TB/HIV activities (WHO/HTM/TB/2004.342; WHO/HIV/2004.09). Additionally, the Expert Group made a recommendation to WHO and partners to provide guidance to NTPs to expand and improve their e-R&R systems as they adopt the new, revised R&R system.
1.4. Next steps
1.4.1. Endorsement The revised forms and registers have been endorsed by the WHO Strategic and Technical Advisory Group for TB (STAG-TB), KNCV, the Union and CDC.
1.4.2. Dissemination and implementation of the revised forms and registers The final version of the revised TB R&R forms will be launched on 30 October 2006 at the Core Group meeting of the Stop TB Partnership Working Groups in Paris, and on 31 October 2006 at the 37th Union World Conference on Lung Health in Paris.
6
Dissemination. The revised forms and registers will be posted on the web and widely circulated to all NTP managers and stakeholders through e-mail and during meetings and country visits. CDs of this document will be distributed to partners and countries through WHO regional offices. Guidelines and training materials on the forms and registers will be also published in WHO publications currently under development, such as the Tuberculosis handbook and the next version of the training courses Management of tuberculosis: training for district TB coordinators and Management of tuberculosis: training for health facility staff. Implementation. Forms, guidelines and training materials will be adopted and adapted at country level based on the generic documents. Implementation of these revisions will be undertaken together with the other new components of the Stop TB Strategy globally by the DOTS Expansion Working Group and at country level by NTPs. Use of most of the revised forms and registers will require on-the-spot training and supervision. Use of additional forms such the Yearly Report on Programme Management in Basic Management Unit (form 10) will require more extensive training. Monitoring of the implementation of these revised forms and registers will require a repeat survey, to be conducted by WHO at the end of 2007.
1.4.3. Electronic TB recording and reporting (e-R&R) E-R&R has not received sufficient attention in TB control and is critical as data demands expand. e-R&R should use the same structure as the paper-based TB information systems. The e-R&R expert group will succeed the R&R expert group and include additional experts recruited for their skills in information technology. The aims are to promote the development and use of e-R&R that conforms to a set of uniform standards. The STB TB Strategy and Health Systems (TBS) team will facilitate and coordinate the work of the e-R&R group. A budgeted plan including technical support will be developed. Next steps are: - Provide different e-RR systems with clear guidelines on when and how to develop
(adapt) a certain system that is most advantageous to the country. - Monitor e-R&R implementation at country level. - Develop guidelines on data quality control for paper and e-R&R systems. - Train a pool of consultants who will be able to support e-R&R implementation. - Explore the e-R&R private market. - Meet regularly (frequency to be defined by TBS).
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Revised TB recording and reporting forms and registers
2. Part I: Essential TB data
Additional or modified data are circled in blue in each form:
8
Removed data are circled in a red dashed line in the current set of forms (annexes, pages 56-71).
Tuberculosis Programme Form 1
Request for Sputum Smear Microscopy Examination
The completed form with results should be sent promptly by laboratory to the referring facility
Referring facility1 _____________________________________________ Date ___________________
Name of patient __________________________________________ Age ______ Sex: M F
Complete address ____________________________________________________________________
___________________________________________________________________________________
Reason for sputum smear microscopy examination:
Diagnosis
OR Follow-up Number of month of treatment: ______ BMU TB Register No. 2 _______________
Name and signature of person requesting examination _______________________________________ 1. Including all public and private health facility/providers 2. Be sure to enter the patient’s BMU TB Register No. for follow-up of patients on chemotherapy
RESULTS (to be completed in the laboratory) Laboratory Serial No. _________________________________________________________
RESULTS
Date collected 3
Sputum Specimen
Visual appearance 4
NEG (1-9) (+) (++) (+++)
1
2
3
3. To be completed by the person collecting the sputum 4. Blood-stained, muco-purulent, saliva Examined by ________________________________________________________________________ Date ____________________________ Signature _______________________________________
9
10
Form 1, Request for Sputum Smear Microscopy Examination Added data (circled in blue) and justification:
• "Referring facility" is added in the subtitle and replaces the item "name of the health facility". This change will facilitate the monitoring of public–private mix (PPM) activities, component 4 of the Stop TB Strategy (engage all care providers), allow a linkage with the added column "referring facility" in the Laboratory Register and form the basis for PPM reporting in the Yearly Report on Programme Management in BMU. The wording is also consistent with the TB Suspects Register and TB Treatment Transfer/Referral form.
• Additional footnote 1 aims to promote the use of this form by all public and private facilities, complying with component 4 of the Stop TB Strategy (engage all care providers), and proficient collaboration.
• Additional footnote 3 allows the monitoring of the number of samples sent and corresponding date of collection.
Modified data (circled in blue) and justification:
• "Sputum smear microscopy examination" is used in place of "sputum examination" (throughout the forms).
• "BMU" is used in place of "District" according to the definition in the Compendium of indicators for monitoring and evaluating national tuberculosis programs (WHO/HTM/TB/2004.344).
• "Visual appearance" is included in the results table allowing a separate answer for each specimen. Laboratory experts considered it important to know the visual appearance of the sputum in order to assess whether or not it was an appropriate sample.
• Results "NEG" and "1–9" replace the previous grading (–) and "scanty", as recommended by the Stop TB laboratory strengthening subgroup and according to the updated laboratory guidelines under development.
• "Name and signature of person requesting examination" replaces "signature of specimen collector". This minor change aims to increase the quality of work by allowing personal assessment and individual responsibility.
• Name of person examining the specimen is added to increase the quality of work by allowing personal assessment and individual responsibility.
Removed data (circled in red in annex 1, page 57) and justification:
• "District" was removed because it is included in the previous question on "complete address".
• "TB suspect No." was removed because the TB Suspects Register is considered an additional TB data (Part III) ie not adopted by all countries. However, in countries using the TB Suspects Register, this information will remain.
• "Disease site" was considered outside the scope of laboratory tasks and thus removed.
Tube
rcul
osis
Pro
gram
me
Form
2
TB
Lab
orat
ory
Reg
iste
r
R
easo
n fo
r spu
tum
sm
ear m
icro
scop
y ex
amin
atio
n
Res
ults
of
sput
um s
mea
r m
icro
scop
y ex
amin
atio
ns 2
Lab.
se
rial
No.
Dat
e sp
ecim
en
rece
ived
N
ame
(in fu
ll)
Sex M/F
Age
C
ompl
ete
addr
ess
(p
atie
nts
for d
iagn
osis
)
Nam
e of
re
ferr
ing
fa
cilit
y 1
Dia
gnos
is (t
ick)
Fo
llow
-up
(mon
th)
1
2
3
BMU
and
TB
R
egis
ter N
o.
(afte
r re
gist
ratio
n)
3
Rem
arks
11
Foo
tnot
es a
ppea
ring
on fi
rst p
age
of th
e re
gist
er o
nly
1
Faci
lity
that
refe
rred
(sen
t) th
e pa
tient
(or s
peci
men
or s
lides
) for
spu
tum
sm
ear m
icro
scop
y ex
amin
atio
n. U
se s
tand
ardi
zed
type
of r
efer
ring
faci
lity
acco
rdin
g to
blo
ck 2
of t
he
Yea
rly R
epor
t on
Pro
gram
me
Man
agem
ent i
n B
MU
. Ref
errin
g fa
cilit
y is
def
ined
as
any
heal
th c
are
prov
ider
s fo
rmal
ly e
ngag
ed in
any
of t
he fo
llow
ing
TB c
ontro
l fun
ctio
ns (D
OTS
): re
ferri
ng T
B s
uspe
cts/
case
s, la
bora
tory
dia
gnos
is, T
B tr
eatm
ent a
nd p
atie
nt s
uppo
rt du
ring
treat
men
t.
2 I
ndic
ate
the
resu
lt fo
r eac
h sp
ecim
en: (
NE
G):
0 A
FB/1
00 fi
elds
; (1-
9) e
xact
num
ber i
f 1 to
9 A
FB/1
00 fi
elds
; (+
): 10
-99
AFB
/100
fiel
ds; (
++):
1-10
AFB
/ fie
ld; (
+++)
: > 1
0 A
FB/ f
ield
3
O
nly
for n
ewly
dia
gnos
ed s
putu
m s
mea
r mic
rosc
opy
posi
tive
TB c
ases
. Det
erm
ine
and
writ
e th
e na
me
of th
e B
MU
and
the
TB R
egis
ter N
o. o
f the
pat
ient
. The
aim
is to
cro
ssch
eck
regu
larly
whe
ther
all
sput
um s
mea
r mic
rosc
opy
posi
tive
patie
nts
are
ente
red
into
a B
MU
TB
Reg
iste
r and
are
rece
ivin
g tre
atm
ent.
12
Form
2, T
B L
abor
ator
y R
egis
ter
Two
colu
mns
hav
e be
en a
dded
to m
onito
r the
PP
M c
ontri
butio
n to
refe
rral a
ctiv
ities
, com
pone
nt 4
of t
he S
top
TB S
trate
gy (e
ngag
e al
l car
e pr
ovid
ers)
and
to c
ross
-ch
eck
or tr
ace
diag
nose
d an
d tre
ated
cas
es. O
ther
cha
nges
are
min
or, a
nd e
xpla
ined
bel
ow.
Add
ed d
ata
(circ
led
in b
lue)
and
just
ifica
tion:
•
Col
umn
7: "N
ame
of re
ferri
ng fa
cilit
y" a
nd fo
otno
te 1
are
key
s to
reco
rdin
g an
d re
porti
ng in
the
Yea
rly R
epor
t on
Pro
gram
me
Man
agem
ent i
n B
MU
, the
P
PM
con
tribu
tion
on re
ferra
l act
iviti
es, c
ompo
nent
4 o
f the
Sto
p TB
Stra
tegy
(eng
age
all c
are
prov
ider
s). L
inka
ge a
nd w
ordi
ng a
re c
onsi
sten
t with
in
form
atio
n re
cord
ed in
form
1, R
eque
st fo
r Spu
tum
Sm
ear M
icro
scop
y E
xam
inat
ion,
TB
Trea
tmen
t Ref
erra
l/Tra
nsfe
r for
m a
nd T
B S
uspe
cts
Reg
iste
r.
List
of r
efer
ring
faci
lity
shou
ld b
e co
nsis
tent
with
the
refe
rral b
ox o
f the
TB
Tre
atm
ent C
ard
and
shou
ld b
e ad
apte
d to
loca
l con
text
. •
Col
umn
8, s
ub-c
olum
ns d
iagn
osis
and
follo
w u
p - "
tick
" and
"mon
th" w
ere
adde
d. T
his
addi
tiona
l inf
orm
atio
n on
mon
th o
f con
trol i
n th
e co
lum
n di
agno
sis
allo
ws
asse
ssm
ent o
f the
mon
th 2
resu
lt w
hich
is c
onsi
dere
d ke
y to
ass
essi
ng th
e qu
ality
of l
abor
ator
y co
ntro
l as
a w
hole
. •
Col
umn
10: "
BM
U a
nd B
MU
TB
Reg
iste
r No.
" and
rela
ted
foot
note
3 a
re a
dded
to c
ross
-che
ck d
iagn
osed
cas
es a
nd tr
eate
d ca
ses
in th
e sa
me
BMU
, an
d tra
ce d
iagn
osed
cas
es w
ho a
re re
ferr
ed to
ano
ther
BM
U.
• R
emin
der:
foot
note
s m
ay a
ppea
r onl
y on
the
first
pag
e of
the
regi
ster
and
not
nec
essa
rily
on e
ach
page
.
Mod
ified
dat
a (c
ircle
d in
blu
e) a
nd ju
stifi
catio
n:
• C
olum
n 2:
"dat
e sp
ecim
en re
ceiv
ed" r
epla
ces
"dat
e". I
t aim
s to
cla
rify
the
reco
rdin
g da
te a
ccor
ding
to re
ceip
t of t
he fi
rst s
et o
f spe
cim
ens.
Thi
s al
low
s fo
r be
tter c
onsi
sten
cy b
etw
een
dist
ricts
and
giv
es th
e po
ssib
ility
to a
sses
s th
e le
ad ti
me
betw
een
the
date
of d
iagn
osis
and
the
date
trea
tmen
t sta
rts,
assu
min
g th
e sp
ecim
en is
exa
min
ed th
e sa
me
day
upon
arr
ival
as
reco
mm
ende
d in
the
WH
O g
uide
lines
. •
Col
umn
6: "A
ddre
ss (p
atie
nts
for d
iagn
osis
)" re
plac
es "c
ompl
ete
addr
ess
(for n
ew p
atie
nts)
". Th
is is
mor
e co
nsis
tent
with
the
wor
ding
use
d in
col
umn
8,
sub-
colu
mn
"dia
gnos
is".
The
com
plet
e ad
dres
s is
not
alw
ays
nece
ssar
y in
this
regi
ster
: if a
pat
ient
doe
s no
t com
e ba
ck fo
r his
pos
itive
resu
lt, h
e sh
ould
be
trac
ed u
sing
the
com
plet
e ad
dres
s av
aila
ble
on th
e “R
eque
st fo
r Spu
tum
Sm
ear M
icro
scop
y E
xam
inat
ion”
form
. •
Col
umn
9: "r
esul
t of s
putu
m s
mea
r mic
rosc
opy
exam
inat
ion"
repl
aces
"Mic
rosc
opy
resu
lt" fo
r wor
ding
con
sist
ency
. Add
ition
al fo
otno
te 2
sta
tes
the
new
sp
ellin
g (N
EG) f
or n
egat
ive
resu
lt an
d ne
w g
radi
ng (1
-9) f
or lo
w p
ositi
ve re
sults
.
R
emov
ed d
ata
(circ
led
in re
d in
ann
ex 3
pag
e 59
) and
just
ifica
tion:
•
Col
umn
6 an
d 9:
min
or e
ditin
g ch
ange
des
crib
ed in
the
abov
e pa
ragr
aph.
Tube
rcul
osis
Pro
gram
me
F
orm
3
13
Tu
berc
ulos
is T
reat
men
t Car
d
BM
U T
B R
egis
ter N
o.__
____
____
___
Nam
e:
___
____
____
____
____
____
____
____
____
____
____
____
____
____
_
Sex
:
M
F
D
ate
of re
gist
ratio
n: _
____
____
____
____
____
____
___
Age
:
__
____
__
Hea
lth fa
cilit
y: _
____
____
____
____
____
____
____
____
Add
ress
: ___
____
____
____
____
____
____
____
____
____
____
____
____
____
_ __
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
__
Dis
ease
site
(che
ck o
ne)
P
ulm
onar
y
Ext
rapu
lmon
ary,
spe
cify
___
____
____
Ty
pe o
f pat
ient
(che
ck o
ne)
N
ew
T
reat
men
t afte
r def
ault
R
elap
se
T
reat
men
t afte
r fai
lure
T
rans
fer i
n
Oth
er, s
peci
fy _
____
____
____
____
__
Nam
e / a
ddre
ss o
f com
mun
ity tr
eatm
ent s
uppo
rter (
if ap
plic
able
) ____
____
____
_
CA
T (I,
II ,
III):
____
____
____
____
____
____
____
____
____
____
____
____
___
I. IN
ITIA
L PH
ASE
- p
resc
ribed
regi
men
and
dos
ages
Sput
um s
mea
r mic
rosc
opy
Mon
th
Dat
e La
b N
o.R
esul
t
Wei
ght
(kg)
0
N
umbe
r of t
ab
lets
per
dos
e an
d do
sage
of S
: (R
HZE
)
S
Ref
erra
l by
: S
elf-r
efer
ral
Com
mun
ity m
embe
r
P
ublic
faci
lity
Priv
ate
faci
lity/
prov
ider
O
ther
, spe
cify
----
----
-----
----
----
--
TB/H
IV
----
----
-
Cot
rimox
azol
e
AR
V
O
ther
R
esul
t*
Dat
eH
IV te
st
CP
T st
art
AR
T st
art
* (N
eg) N
egat
ive; (
Ind
eter
mina
te; (
ND) N
ot D
one/
unkn
ow
(Pos
) Pos
itive;
) I
n
Tick
app
ropr
iate
box
afte
r the
dru
gs h
ave
been
adm
inis
tere
d th
roug
h th
e nu
mbe
r of d
ays
supp
lied.
Ø =
dru
gs n
ot ta
ken
D
aily
sup
ply:
ent
er
. Per
iodi
c su
pply
: ent
er X
on
day
whe
n dr
ugs
are
colle
cted
and
dra
w a
hor
izon
tal l
ine
(
)
Day
M
onth
1
2 3
4 5
6 7
8 9
1011
1213
1415
1617
18
1920
2122
2324
2526
2728
2930
31
Tube
rcul
osis
Pro
gram
me
Fo
rm 3
(con
tinue
d)
II. C
ON
TIN
UA
TIO
N P
HA
SE
Com
men
ts: _
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
___
____
____
____
____
____
____
____
____
____
____
____
____
___
____
____
____
____
____
____
____
____
____
____
____
____
___
____
____
____
____
____
____
____
____
____
____
____
____
___
Num
ber o
f tab
lets
per
dos
e
(RH
)
(R
HE
)O
ther
Dai
ly s
uppl
y: e
nter
.
Per
iodi
c su
pply
, ent
er X
on
day
whe
n dr
ugs
are
colle
cted
and
dra
w a
hor
izon
tal l
ine
(
) th
roug
h th
e nu
mbe
r of d
ays
supp
lied.
Ø =
dru
gs n
ot ta
ken
D
ay
Mon
th
1
23
45
67
89
1011
1213
1415
1617
1819
2021
2223
2425
2627
2829
3031
X-ra
y (a
t sta
rt)
Dat
e:
Res
ults
(-),
(+),
ND
Trea
tmen
t out
com
e D
ate
of d
ecis
ion
____
C
ure
T
reat
men
t com
plet
ed
Die
d
T
reat
men
t fai
lure
D
efau
lt
T
rans
fer o
ut
HIV
car
e P
re A
RT
Reg
iste
r No.
CD
4 re
sult
A
RT
elig
ibili
ty (Y
/N/U
nkno
wn)
D
ate
elig
ibilit
y as
sess
ed
A
RT
Reg
iste
r No.
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
__
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
__
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
__
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
__
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
__
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
__
Nam
e an
d ad
dres
s of
con
tact
per
son:
___
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
___
14
Tube
rcul
osis
Pro
gram
me
Form
3, T
uber
culo
sis
Trea
tmen
t car
d
Add
ed d
ata
(circ
led
in b
lue)
and
just
ifica
tion:
Fr
ont
• Th
e bl
ock
on re
ferr
al is
add
ed to
allo
w re
cord
ing
of th
e co
mm
unity
con
tribu
tion
of th
e to
refe
rral a
ctiv
ities
in th
e TB
Reg
iste
r (A
dditi
onal
dat
a, P
art
III, f
orm
D) a
nd re
porti
ng o
f it i
n th
e Y
early
Rep
ort o
n Pr
ogra
mm
e M
anag
emen
t in
BM
U (f
orm
10,
blo
ck 3
). Th
is c
ompl
ies
with
com
pone
nt 5
of t
he
Sto
p TB
Stra
tegy
(em
pow
er p
eopl
e w
ith T
B, a
nd c
omm
uniti
es).
A c
omm
unity
mem
ber i
s de
fined
as
train
ed a
nd re
gula
rly s
uper
vise
d in
form
al
prac
titio
ners
, com
mun
ity w
orke
rs/v
olun
teer
s, fa
mily
mem
bers
, frie
nds
prov
idin
g se
rvic
es o
utsi
de a
faci
lity
(hea
lth in
stitu
tion)
. Lis
t of r
efer
ral b
ox o
f th
e TB
Tre
atm
ent C
ard
shou
ld b
e co
nsis
tent
with
the
refe
rring
faci
lity
in th
e B
MU
TB
Reg
iste
r and
in th
e Ye
arly
Rep
ort o
n P
rogr
amm
e M
anag
emen
t in
BM
U a
nd s
houl
d be
ada
pted
to th
e lo
cal c
onte
xt.
• Tw
o bl
ocks
on
TB/H
IV a
ctiv
ities
and
on
othe
r dru
gs a
re a
dded
to a
llow
reco
rdin
g of
the
TB/H
IV a
ctiv
ities
in th
e B
MU
TB
Reg
iste
r and
repo
rting
in
the
quar
terly
repo
rts. T
his
com
plie
s w
ith c
ompo
nent
2 o
f the
Sto
p TB
Stra
tegy
(add
ress
TB
/HIV
). M
easu
res
to im
prov
e co
nfid
entia
lity
shou
ld
acco
mpa
ny re
cord
ing
of H
IV s
tatu
s. T
he T
B T
reat
men
t Car
d m
ust b
e ac
cess
ible
onl
y by
thos
e w
ho n
eed
to k
now
the
info
rmat
ion,
usu
ally
thos
e pr
ovid
ing
dire
ct p
atie
nt c
are.
It s
houl
d be
sto
red
in a
sec
ure
loca
tion
(suc
h as
a lo
cked
cab
inet
). C
onfid
entia
lity
appl
ies
to a
ll of
the
reco
rdin
g an
d re
porti
ng fo
rms,
rega
rdle
ss o
f whe
ther
the
form
s co
ntai
n in
form
atio
n on
HIV
sta
tus.
Ba
ck
• Tw
o bl
ocks
on
X-r
ay a
nd H
IV c
are
have
bee
n ad
ded
to ta
ke in
to a
ccou
nt th
e in
crea
sed
use
of X
-ray
and
HIV
car
e fo
r HIV
-pos
itive
TB
case
s.
Mod
ified
dat
a (c
ircle
in b
lue)
and
just
ifica
tion:
Fr
ont
• C
ateg
orie
s I,
II an
d III
are
gro
uped
into
one
box
. •
Ant
i-TB
dru
gs a
nd d
oses
are
gro
uped
into
thre
e TB
dru
g pr
esen
tatio
ns.
• Fo
otno
te o
n ta
ble
of d
rug
adm
inis
tratio
n fo
r ini
tial a
nd c
ontin
uatio
n ph
ase
is s
imila
r with
the
four
type
s of
mar
ks (
, X
,
and
Ø).
Thes
e m
arks
faci
litat
e th
e ca
lcul
atio
n of
dru
gs s
elf-a
dmin
iste
red,
giv
en to
sup
porte
rs, o
r sup
ervi
sed
by h
ealth
sta
ff.
Back
•
Ant
i-TB
dru
gs a
nd d
oses
are
gro
uped
into
thre
e TB
dru
g pr
esen
tatio
ns.
R
emov
ed d
ata
(circ
led
in re
d in
ann
ex 4
, pag
e 60
) and
just
ifica
tion:
Fr
ont
• B
oxes
on
drug
freq
uenc
y ar
e re
mov
ed a
ccor
ding
to th
e pr
efer
red
TB re
gim
en (W
HO
/CD
S/T
B/2
003.
313,
revi
sed
chap
ter 4
, Jun
e 20
04
http
://w
ww
.who
.int/t
b/pu
blic
atio
ns/c
ds_t
b_20
03_3
13/e
n/in
dex.
htm
l).
• Fo
ur c
olum
ns o
n nu
mbe
r of d
oses
this
mon
th a
nd to
tal d
oses
giv
en, a
nd d
ate
and
dose
s gi
ven
to th
e tre
atm
ent s
uppo
rter h
ave
been
rem
oved
be
caus
e th
ey w
ere
cons
ider
ed re
dund
ant w
ith th
e in
form
atio
n pr
ovid
ed in
the
tabl
e on
dai
ly/m
onth
ly d
istri
butio
n of
dru
gs.
Back
•
Box
es o
n dr
ug fr
eque
ncy
have
bee
n re
mov
ed a
ccor
ding
to th
e pr
efer
red
TB re
gim
en.
• Tw
o co
lum
ns o
n nu
mbe
r of d
oses
this
mon
th a
nd to
tal d
oses
giv
en h
ave
been
rem
oved
bec
ause
they
wer
e co
nsid
ered
redu
ndan
t with
the
info
rmat
ion
prov
ided
in th
e ta
ble
on d
aily
/mon
thly
dis
tribu
tion
of d
rugs
.
15
Tube
rcul
osis
Pro
gram
me
Fo
rm 4
Tu
berc
ulos
is Id
entit
y C
ard
Nam
e __
____
____
____
____
____
BM
U T
B R
egis
ter N
o. _
____
A
ddre
ss _
____
____
____
____
____
_ D
ate
of re
gist
ratio
n: _
____
__
Sex
: M
F
Age
___
___
D
ate
treat
men
t sta
rt __
____
_ H
ealth
faci
lity:
___
____
____
____
____
____
____
____
____
____
___
Sup
porte
r (na
me
and
addr
ess)
___
____
____
____
____
____
____
___
Sput
um s
mea
r mic
rosc
opy
Mon
th
D
ate
Lab
No.
Res
ult
Wei
ght
(kg)
0
Dis
ease
site
(che
ck o
ne)
Pul
mon
ary
E
xtra
pulm
onar
y, s
peci
fy _
____
__
Type
of p
atie
nt (c
heck
one
) N
ew
Tre
atm
ent a
fter d
efau
lt
Rel
apse
T
reat
men
t afte
r fai
lure
T
rans
fer i
n
Oth
er s
peci
fy _
____
____
____
_ I.
INIT
IAL
PHA
SE
C
AT
(I, II
, III
):
(R
HZE
)
S
O
ther
Dru
gs a
nd d
osag
e:
II.
CO
NTI
NU
ATI
ON
PH
ASE
(RH
)
(RH
E)
Oth
er
Dru
gs a
nd d
osag
e:
App
oint
men
t dat
es:
____
____
____
____
____
____
____
____
___
____
____
____
____
____
____
____
____
____
____
____
____
__
____
____
____
____
____
____
____
____
____
____
____
____
__
____
____
____
____
____
____
____
____
____
____
____
____
__
____
____
____
____
____
____
____
____
____
____
____
____
__
____
____
____
____
____
____
____
____
____
____
____
____
__
R
EM
EM
BE
R
16
Form
4, T
B Id
entit
y C
ard
Id
entit
y ca
rd re
mai
ns s
imila
r with
min
or m
odifi
catio
ns.
Add
ed d
ata
(circ
led
in b
lue)
and
just
ifica
tion:
non
e M
odifi
ed d
ata
(circ
led
in b
lue)
and
just
ifica
tion:
•
Cat
egor
ies
I, II,
and
III a
re g
roup
ed in
to o
ne b
ox.
• A
nti-T
B d
rugs
and
dos
es a
re g
roup
ed in
to th
ree
TB d
rug
pres
enta
tions
.
Rem
oved
dat
a (c
ircle
d in
red)
and
just
ifica
tion:
non
e
17
Tube
rcul
osis
Pro
gram
me
Fo
rm 5
18
Bas
ic M
anag
emen
t Uni
t TB
Reg
iste
r – L
eft s
ide
of th
e re
gist
er b
ook
Type
of p
atie
nt 3
D
ate
of
regi
stra
tion
BM
U
TB N
o.
Nam
e
Sex M/F
Age
Add
ress
H
ealth
fa
cilit
y1
Dat
e tre
atm
ent
star
ted
Trea
tmen
t ca
tego
ry 2
Site P /
EPN
RF
D
T O
Foot
note
s ap
pear
ing
on fi
rst p
age
of th
e re
gist
er o
nly.
1
Faci
lity
whe
re p
atie
nt’s
trea
tmen
t car
d is
kep
t. In
cas
e se
vera
l cop
ies
are
kept
, the
mos
t per
iphe
ral f
acilit
y sh
ould
be
ente
red.
Use
sta
ndar
dize
d ty
pe o
f hea
lth
faci
litie
s ac
cord
ing
to b
lock
2 o
f the
Yea
rly R
epor
t on
Pro
gram
me
Man
agem
ent i
n B
MU
. Hea
lth fa
cilit
y is
def
ined
as
any
heal
th in
stitu
tion
with
hea
lth c
are
prov
ider
s fo
rmal
ly e
ngag
ed in
any
of t
he fo
llow
ing
TB c
ontro
l fun
ctio
ns (D
OTS
): re
ferr
ing
TB s
uspe
cts/
case
s, la
bora
tory
dia
gnos
is, T
B tr
eatm
ent a
nd p
atie
nt
supp
ort d
urin
g tre
atm
ent.
2 En
ter t
he tr
eatm
ent c
ateg
ory:
CA
T I:
New
cas
e of
spu
tum
sm
ear m
icro
scop
y po
sitiv
e, s
ever
e sp
utum
sm
ear m
icro
scop
y ne
gativ
e P
TB &
EP
TB e
.g. 2
(RH
ZE)/4
(RH
)C
AT
II: R
e-tre
atm
ent e
.g. 2
(RH
ZE)S
/1(R
HZE
)/5(R
HE)
C
AT
III: N
ew s
putu
m s
mea
r mic
rosc
opy
nega
tive
PTB
and
EP
TB
e
.g. 2
(RH
ZE)/4
(RH
)
3 Ti
ck o
nly
one
colu
mn:
N
=New
– A
pat
ient
who
has
nev
er h
ad tr
eatm
ent f
or T
B or
who
has
take
n an
titub
ercu
losi
s dr
ugs
for l
ess
than
1 m
onth
. R
=Rel
apse
– A
pat
ient
pre
viou
sly
treat
ed fo
r TB
, dec
lare
d cu
red
or
treat
men
t com
plet
ed, a
nd w
ho is
dia
gnos
ed w
ith b
acte
riolo
gica
l (+)
TB
(s
putu
m s
mea
r mic
rosc
opy
or c
ultu
re).
F=Tr
eatm
ent a
fter f
ailu
re –
A p
atie
nt w
ho is
sta
rted
on a
re-tr
eatm
ent r
egim
en
afte
r hav
ing
faile
d pr
evio
us tr
eatm
ent.
D=T
reat
men
t afte
r def
ault
– A
pat
ient
who
retu
rns
to tr
eatm
ent,
posi
tive
bact
erio
logi
cally
, fol
low
ing
inte
rrup
tion
of tr
eatm
ent f
or 2
or m
ore
cons
ecut
ive
mon
ths.
T=
Tran
sfer
in –
A p
atie
nt w
ho h
as b
een
trans
ferr
ed fr
om a
noth
er T
B R
egis
ter t
o co
ntin
ue tr
eatm
ent.
This
gro
up is
exc
lude
d fro
m th
e Q
uarte
rly R
epor
ts o
n TB
C
ase
Reg
istra
tion
and
on T
reat
men
t Out
com
e.
O=O
ther
pre
viou
sly
trea
ted–
All
case
s th
at d
o no
t fit
the
abov
e de
finiti
ons.
Thi
s gr
oup
incl
udes
spu
tum
sm
ear m
icro
scop
y po
sitiv
e ca
ses
with
unk
now
n hi
stor
y or
unk
now
n ou
tcom
e of
pre
viou
s tre
atm
ent,
prev
ious
ly tr
eate
d sp
utum
sm
ear
mic
rosc
opy
nega
tive,
pre
viou
sly
treat
ed E
P, a
nd c
hron
ic c
ase
(i.e.
a p
atie
nt
who
is s
putu
m s
mea
r mic
rosc
opy
posi
tive
at th
e en
d of
re-tr
eatm
ent r
egim
en).
Tube
rcul
osis
Pro
gram
me
Fo
rm 5
(con
tinue
d)
19
Bas
ic M
anag
emen
t Uni
t TB
Reg
iste
r – R
ight
sid
e of
the
regi
ster
boo
k
Res
ults
of s
putu
m s
mea
r mic
rosc
opy
and
othe
r exa
min
atio
n Tr
eatm
ent o
utco
me
& d
ate
TB/H
IV a
ctiv
ities
R
emar
ks
Bef
ore
treat
men
t 2
or 3
mon
ths
15
mon
ths
End
of t
reat
men
t
D
ate
Out
com
e5A
RT
Y/N
S
tart
date
CP
T Y/
N
Sta
rt da
te
Spu
tum
sm
ear
mic
ros-
copy
re
sult 2
Dat
e/
Lab.
N
o,
HIV
re
sult3
Dat
e
X-ra
y R
esul
t4S
putu
m
smea
r m
icro
s-co
py
resu
lt2
Dat
e/
Lab.
N
o.
Spu
tum
sm
ear
mic
ros-
copy
re
sult 2
Dat
e/
Lab.
N
o.
Spu
tum
sm
ear
mic
ros-
copy
re
sult 2
Dat
e/
Lab.
N
o.
Cure
Treatment Completed
Treatment Failure
Died
Default
Transfer
Foo
tnot
es a
ppea
ring
on fi
rst p
age
of th
e re
gist
er o
nly
1 C
AT
I pat
ient
s ha
ve fo
llow
-up
sput
um s
mea
r mic
rosc
opy
exam
inat
ion
at 2
mon
ths;
CA
T II
patie
nts
have
follo
w-u
p sp
utum
sm
ear m
icro
scop
y ex
amin
atio
n at
3
mon
ths.
CA
T I p
atie
nts
with
initi
al p
hase
of t
reat
men
t ext
ende
d to
3 m
onth
s ha
ve fo
llow
-up
sput
um e
xam
inat
ions
at 2
AN
D 3
mon
ths
with
resu
lts re
gist
ered
in th
e sa
me
box.
2
(ND
): N
ot d
one;
(NEG
): 0
AFB
/100
fiel
ds; (
1-9)
: exa
ct n
umbe
r if 1
to 9
AFB
/100
fiel
ds; (
+): 1
0-99
AFB
/100
fiel
ds; (
++):
1-10
AFB
/ fie
ld; (
+++)
: > 1
0 A
FB/ f
ield
3
(Pos
): P
ositi
ve; (
Neg
): N
egat
ive;
(I):
Inde
term
inat
e; (N
D):
Not
Don
e/un
know
n. D
ocum
ente
d ev
iden
ce o
f HIV
test
per
form
ed d
urin
g or
bef
ore
TB tr
eatm
ent i
s re
porte
d he
re. M
easu
res
to im
prov
e co
nfid
entia
lity
shou
ld a
ccom
pany
reco
rdin
g of
HIV
sta
tus
in th
e TB
pat
ient
reco
rd o
r reg
iste
rs
4 (P
os):
Sug
gest
ive
of T
B, (
Neg
): N
ot s
ugge
stiv
e of
TB
; (N
D):
Not
Don
e.
5 Ti
ck o
nly
one
colu
mn
for e
ach
patie
nt:
C
ure:
Spu
tum
sm
ear m
icro
scop
y po
sitiv
e pa
tient
who
was
spu
tum
neg
ativ
e in
the
last
mon
th o
f tre
atm
ent a
nd o
n at
leas
t one
pre
viou
s oc
casi
on.
Trea
tmen
t com
plet
ed: P
atie
nt w
ho h
as c
ompl
eted
trea
tmen
t but
who
doe
s no
t mee
t the
crit
eria
to b
e cl
assi
fied
as a
cur
e or
a fa
ilure
. Tr
eatm
ent f
ailu
re: N
ew p
atie
nt w
ho is
spu
tum
sm
ear m
icro
scop
y po
sitiv
e at
5 m
onth
s or
late
r dur
ing
treat
men
t, or
who
is s
witc
hed
to C
ateg
ory
IV tr
eatm
ent
beca
use
sput
um tu
rned
out
to b
e M
DR
TB. P
revi
ousl
y-tre
ated
pat
ient
who
is s
putu
m s
mea
r mic
rosc
opy
posi
tive
at th
e en
d of
his
re-tr
eatm
ent o
r who
is s
witc
hed
to
Cat
egor
y IV
trea
tmen
t bec
ause
spu
tum
turn
ed o
ut to
be
MD
RTB
. D
ied:
Pat
ient
who
die
s fro
m a
ny c
ause
dur
ing
the
cour
se o
f tre
atm
ent.
Def
ault:
Pat
ient
who
se tr
eatm
ent w
as in
terr
upte
d fo
r 2 c
onse
cutiv
e m
onth
s or
mor
e.
Tran
sfer
out
: Pat
ient
who
has
bee
n tra
nsfe
rred
to a
hea
lth fa
cilit
y in
ano
ther
BM
U a
nd fo
r who
m tr
eatm
ent o
utco
me
is n
ot k
now
n.
20
Form
5, B
MU
TB
Reg
iste
r A
dded
dat
a (c
ircle
d in
blu
e) a
nd ju
stifi
catio
n:
Left
side
: dat
a fo
r TB
cas
e re
gist
ratio
n (i.
e. b
efor
e tre
atm
ent s
tart)
•
Rem
inde
r: fo
otno
tes
may
app
ear o
nly
on th
e fir
st p
age
of th
e re
gist
er a
nd n
ot n
eces
saril
y on
eac
h pa
ge.
• Fo
otno
tes
on "h
ealth
faci
lity"
col
umn
7 ai
m to
cla
rify
the
loca
tion
of th
e TB
Tre
atm
ent C
ard
in th
e se
tting
of d
ecen
traliz
ed T
B s
ervi
ces.
Col
umn
7als
o hi
ghlig
hts
the
links
with
the
Yea
rly R
epor
t on
Pro
gram
me
Man
agem
ent i
n B
MU
and
inst
ruct
s ho
w to
reco
rd a
nd re
port
on th
e PP
M
cont
ribut
ion
to tr
eatm
ent (
com
pone
nt 4
of t
he S
top
TB S
trate
gy) i
n th
e Y
early
Rep
ort o
n P
rogr
amm
e M
anag
emen
t in
BM
U.
• D
efin
ition
of t
reat
men
t fai
lure
has
bee
n m
odifi
ed a
ccor
ding
to th
e S
top
TB W
orki
ng G
roup
on
MD
R-T
B.
• Fo
otno
te o
n th
e la
st c
olum
n "ty
pe o
f pat
ient
" sub
-col
umn
"Oth
er p
revi
ousl
y tre
ated
" pro
vide
s a
new
def
initi
on o
f oth
er c
ases
whi
ch a
ims
to
diffe
rent
iate
pre
viou
sly
treat
ed c
ases
with
pos
itive
spu
tum
sm
ear m
icro
scop
y (R
elap
se, T
reat
men
t afte
r fai
lure
and
Tre
atm
ent a
fter d
efau
lt) fr
om
othe
r typ
es o
f pre
viou
sly
treat
ed c
ases
. R
ight
sid
e: d
ata
for T
B tr
eatm
ent o
utco
me
• H
IV te
st re
sult
is p
lace
d at
the
begi
nnin
g of
the
right
sid
e pa
ge to
be
cons
iste
nt w
ith th
e re
com
men
ded
test
at t
he b
egin
ning
of T
B tr
eatm
ent (
or
even
ear
lier)
i.e. t
o te
st a
ll TB
cas
es a
t the
beg
inni
ng o
f tre
atm
ent.
This
info
rmat
ion
will
be
repo
rted
in th
e Q
uarte
rly R
epor
t on
TB C
ase
Reg
istra
tion
only
. Mea
sure
s to
impr
ove
conf
iden
tialit
y sh
ould
acc
ompa
ny re
cord
ing
of H
IV s
tatu
s. T
he B
MU
TB
Reg
iste
r mus
t be
acce
ssib
le o
nly
by th
ose
who
nee
d to
kno
w th
e in
form
atio
n, u
sual
ly th
ose
prov
idin
g di
rect
pat
ient
car
e. It
sho
uld
be s
tore
d in
a s
ecur
e lo
catio
n (s
uch
as a
lock
ed
cabi
net).
Con
fiden
tialit
y ap
plie
s to
all
of th
e re
cord
ing
and
repo
rting
form
s, re
gard
less
of w
heth
er th
e fo
rms
cont
ain
info
rmat
ion
on H
IV s
tatu
s.
• A
dditi
onal
col
umn
on "X
-ray
befo
re tr
eatm
ent"
and
its fo
otno
te a
re c
onsi
sten
t with
the
incr
ease
d us
e of
X-r
ay in
the
diag
nosi
s of
spu
tum
sm
ear
mic
rosc
opy
nega
tive
TB.
•
Dat
e of
trea
tmen
t out
com
e is
pre
sent
ed a
s a
sepa
rate
col
umn.
•
Two
colu
mns
wer
e ad
ded
on T
B/H
IV a
ctiv
ities
(AR
T, C
PT)
to c
ompl
y w
ith th
e S
top
TB S
trate
gy c
ompo
nent
2 (T
B/H
IV a
ctiv
ity).
They
are
incl
uded
in
this
pag
e be
caus
e th
ey a
re p
rovi
ded
durin
g th
e co
urse
of T
B tr
eatm
ent (
even
if s
tarte
d ea
rlier
). •
Foot
note
2 p
rese
nts
sput
um s
mea
r mic
rosc
opy
resu
lts a
ccor
ding
to g
uida
nce
prov
ided
by
the
Sto
p TB
sub
grou
p on
labo
rato
ry s
treng
then
ing
and
acco
rdin
g to
the
TB L
abor
ator
y R
egis
ter r
ecor
ding
. M
odifi
ed d
ata
(circ
led
in b
lue)
and
just
ifica
tion:
•
Title
: "D
istri
ct" i
s re
plac
ed b
y “B
asic
Man
agem
ent U
nit"
acco
rdin
g to
the
defin
ition
in th
e C
ompe
ndiu
m o
f ind
icat
ors
for m
onito
ring
and
eval
uatin
g na
tiona
l tub
ercu
losi
s pr
ogra
ms
(WH
O/H
TM/T
B/2
004.
344)
, pag
e 10
. •
"Com
plet
e ad
dres
s" is
repl
aced
by
"add
ress
" sin
ce th
e co
mpl
ete
addr
ess
is g
iven
on
the
TB T
reat
men
t Car
d an
d do
es n
ot n
eed
to b
e re
peat
ed
here
.
Rem
oved
dat
a (c
ircle
d in
red
in a
nnex
5, p
age
62) a
nd ju
stifi
catio
n: n
one
Tube
rcul
osis
Pro
gram
me
Fo
rm 6
21
Qua
rter
ly R
epor
t on
TB C
ase
Reg
istr
atio
n in
Bas
ic M
anag
emen
t Uni
t N
ame
of B
MU
: __
____
____
____
____
__
Fac
ility
:___
____
____
____
____
____
____
__
Nam
e of
TB
Coo
rdin
ator
:___
____
____
____
___
S
igna
ture
: __
____
____
____
____
__
Patie
nts
regi
ster
ed d
urin
g1
__
____
qua
rter
of y
ear_
____
_
Dat
e of
com
plet
ion
of th
is fo
rm:
____
____
____
____
____
_
Blo
ck 1
: All
TB c
ases
regi
ster
ed 2
Pulm
onar
y sp
utum
sm
ear m
icro
scop
y po
sitiv
e N
ew p
ulm
onar
y sp
utum
sm
ear m
icro
scop
y ne
gativ
e
Pulm
onar
y sp
utum
sm
ear m
icro
scop
y no
t do
ne /
not a
vaila
ble
New
ext
rapu
lmon
ary
Prev
ious
ly tr
eate
d N
ew
case
s R
elap
ses
Afte
r fa
ilure
Af
ter
defa
ult
0-4
yrs
5-14
yr
s >
15
yrs
0-4
yrs
5-14
yr
s >
15
yrs
0-4
yrs
5-14
yr
s >
15
yrs
Oth
er
prev
ious
ly
treat
ed 3
TOTA
L Al
l cas
es
Blo
ck 2
. New
pul
mon
ary
sput
um s
mea
r mic
rosc
opy
posi
tive
case
s –
Age
gro
up
S
ex0-
45-
1415
–24
25–3
435
–44
45–5
455
–64
> 65
To
tal
M
F
Blo
ck 3
: Lab
orat
ory
activ
ity -
sput
um s
mea
r mic
rosc
opy4
B
lock
4: T
B/H
IV a
ctiv
ities
2
No.
of T
B s
uspe
cts
exam
ined
for d
iagn
osis
by
sput
um s
mea
r mic
rosc
opy
No.
of T
B s
uspe
cts
with
po
sitiv
e sp
utum
sm
ear
mic
rosc
opy
resu
lt
No.
pat
ient
s te
sted
for H
IV
befo
re o
r dur
ing
TB tr
eatm
ent 5
No.
pat
ient
s H
IV
posi
tive
5
N
ew s
putu
m s
mea
r m
icro
scop
y po
sitiv
e TB
Al
l TB
case
s
1
Reg
istra
tion
perio
d is
bas
ed o
n da
te o
f reg
istra
tion
of c
ases
in th
e TB
Reg
iste
r, fo
llow
ing
the
star
t of t
reat
men
t. Q
1: 1
Jan
uary
–31
Mar
ch; Q
2:1
Apr
il–30
Jun
e; Q
3: 1
Jul
y–30
S
epte
mbe
r; Q
4:1
Oct
ober
–31
Dec
embe
r. 2
‘Tra
nsfe
rred
in’ a
nd c
hron
ic c
ases
are
exc
lude
d. In
are
as ro
utin
ely
usin
g cu
lture
, a s
epar
ate
form
for u
nit u
sing
cul
ture
sho
uld
be u
sed.
3
Oth
er p
revi
ousl
y tre
ated
cas
es in
clud
e pu
lmon
ary
case
s w
ith u
nkno
wn
hist
ory
of p
revi
ous
treat
men
t, pr
evio
usly
trea
ted
sput
um s
mea
r mic
rosc
opy
nega
tive
pulm
onar
y ca
ses
and
prev
ious
ly tr
eate
d ex
trapu
lmon
ary
case
s. ‘T
rans
ferre
d in
’ and
chr
onic
cas
es a
re e
xclu
ded.
4
Dat
a co
llect
ed fr
om th
e TB
Lab
orat
ory
Reg
iste
r bas
ed o
n “D
ate
spec
imen
rece
ived
” in
the
labo
rato
ry d
urin
g th
e qu
arte
r, w
ithou
t inc
ludi
ng p
atie
nts
with
exa
min
atio
n be
caus
e of
follo
w-u
p.
5 D
ocum
ente
d ev
iden
ce o
f HIV
test
s (a
nd re
sults
) per
form
ed in
any
reco
gniz
ed fa
cilit
y be
fore
TB
dia
gnos
is o
r dur
ing
TB tr
eatm
ent (
till e
nd o
f the
qua
rter)
shou
ld b
e re
porte
d he
re.
22
Form
6, Q
uart
erly
Rep
ort o
n TB
Cas
e R
egis
trat
ion
in B
asic
Man
agem
ent U
nit
Add
ed d
ata
(circ
led
in b
lue)
and
just
ifica
tion:
•
"Bas
ic M
anag
emen
t Uni
t" is
add
ed in
the
title
acc
ordi
ng to
the
defin
ition
in th
e C
ompe
ndiu
m o
f ind
icat
ors
for m
onito
ring
and
eval
uatin
g na
tiona
l tu
berc
ulos
is p
rogr
ams
(WH
O/H
TM/T
B/2
004.
344)
, pag
e 10
. •
Pul
mon
ary
sput
um s
mea
r mic
rosc
opy
not d
one/
not a
vaila
ble
is a
dded
to m
onito
r cas
es w
ithou
t spu
tum
sm
ear m
icro
scop
y ex
amin
atio
n.
Cor
rect
ive
mea
sure
s to
dec
reas
e th
e nu
mbe
r of d
iagn
osed
cas
es w
ithou
t spu
tum
sm
ear m
icro
scop
y ar
e ex
pect
ed if
bet
ter r
epor
ted.
•
Age
bre
akdo
wn
0–14
yea
rs is
div
ided
into
two
paed
iatri
c gr
oups
(0–4
yea
rs a
nd 5
–14
year
s).
• B
lock
4 o
n TB
/HIV
act
iviti
es w
as a
dded
as
HIV
test
ing
and
resu
lts a
re th
e co
rner
ston
e of
TB/
HIV
act
iviti
es a
nd H
IV te
stin
g is
reco
mm
ende
d to
be
perfo
rmed
bef
ore
TB tr
eatm
ent s
tarts
(eve
ntua
lly a
mon
g TB
sus
pect
s or
bef
ore
bein
g re
ferr
ed to
faci
litie
s w
ith c
apac
ity to
dia
gnos
e TB
). B
reak
dow
n by
spu
tum
sm
ear m
icro
scop
y po
sitiv
e ca
ses
and
all T
B ca
ses
is p
ropo
sed
to m
onito
r the
HIV
pos
itivi
ty ra
te a
mon
g co
nfirm
ed s
putu
m
smea
r mic
rosc
opy
posi
tive
TB c
ases
. M
odifi
ed d
ata
(circ
led
in b
lue)
and
just
ifica
tion:
•
Title
: "D
istri
ct" i
s re
plac
ed b
y “B
asic
Man
agem
ent U
nit"
acco
rdin
g to
the
defin
ition
in th
e C
ompe
ndiu
m o
f ind
icat
ors
for m
onito
ring
and
eval
uatin
g na
tiona
l tub
ercu
losi
s pr
ogra
ms
(WH
O/H
TM/T
B/2
004.
344)
, pag
e 10
. •
Sm
ear (
+) a
nd s
mea
r (–)
are
spe
lt ou
t as
"spu
tum
sm
ear m
icro
scop
y po
sitiv
e" a
nd "s
putu
m s
mea
r mic
rosc
opy
nega
tive.
" •
"Oth
er" b
ecam
e "o
ther
pre
viou
sly
treat
ed" a
nd th
e fo
otno
te d
efin
ition
is m
ore
deta
iled
and
spec
ific
than
in th
e pr
evio
us v
ersi
on.
Pre
viou
sly
treat
ed s
putu
m s
mea
r mic
rosc
opy
nega
tive
pulm
onar
y ca
ses
and
prev
ious
ly tr
eate
d ex
trapu
lmon
ary
case
s ar
e m
ore
clea
rly in
clud
ed in
this
gro
up
in th
is v
ersi
on.
• B
lock
3 o
n la
bora
tory
act
iviti
es w
as in
clud
ed in
the
quar
terly
repo
rt on
pro
gram
me
man
agem
ent b
ut ra
rely
ado
pted
. Inc
lusi
on o
f the
se it
ems
in
this
repo
rt w
ill en
sure
the
prop
er fe
edba
ck o
n la
bora
tory
act
ivity
.
Rem
oved
dat
a (c
ircle
d in
red
in a
nnex
7 p
age
65) a
nd ju
stifi
catio
n: n
one
Tube
rcul
osis
Pro
gram
me
Fo
rm 7
23
Qua
rter
ly R
epor
t on
TB T
reat
men
t Out
com
e an
d TB
/HIV
Act
iviti
es in
BM
U
N
ame
of B
MU
: __
____
____
____
____
__
Fac
ility
:___
____
____
____
____
____
____
____
___
Nam
e of
TB
Coo
rdin
ator
:___
____
____
____
____
Sig
natu
re:
____
____
____
____
____
___
Pat
ient
s re
gist
ered
dur
ing1
__
____
qua
rter
of y
ear_
____
_
Dat
e of
com
plet
ion
of th
is fo
rm:
____
____
____
_
Blo
ck 1
: TB
trea
tmen
t out
com
es 1
Trea
tmen
t out
com
es
Type
of c
ase
To
tal n
umbe
r of
patie
nts
regi
ster
ed
durin
g qu
arte
r *
Cur
e ( 1
)
Trea
tmen
t co
mpl
eted
( 2
)
Die
d ( 3
)
Trea
tmen
t fa
ilure
2
( 4 )
Def
ault
( 5
)
Tran
sfer
out
( 6 )
Tota
l num
ber
eval
uate
d fo
r ou
tcom
es:
(sum
of 1
to 6
)
New
spu
tum
sm
ear m
icro
scop
y po
sitiv
e
Pre
viou
sly
treat
ed s
putu
m s
mea
r m
icro
scop
y po
sitiv
e
All
othe
r cas
es (
Spu
tum
sm
ear
nega
tive,
sm
ear n
ot d
one,
EP
, oth
er
prev
ious
ly tr
eate
d 3 )
* The
se n
umbe
rs a
re tr
ansf
erre
d fro
m th
e Q
uarte
rly R
epor
t on
TB C
ase
Reg
istra
tion
for t
he a
bove
qua
rter.
Spe
cify
any
exc
lusi
on. _
____
____
____
____
___
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
___
Blo
ck 2
: TB
/HIV
act
iviti
es 1
N
o. p
atie
nts
on C
PT
4N
o. p
atie
nts
on A
RT
5
All T
B ca
ses
1 Q
uarte
r: Th
is fo
rm a
pplie
s to
pat
ient
s re
gist
ered
(rec
orde
d in
the
BM
U T
B R
egis
ter)
in th
e qu
arte
r tha
t end
ed 1
2 m
onth
s ag
o. F
or e
xam
ple,
if c
ompl
etin
g th
is fo
rm a
t the
clo
se
of th
e se
cond
qua
rter t
hen
reco
rd d
ata
on p
atie
nts
regi
ster
ed in
the
2nd
quar
ter o
f the
pre
viou
s ye
ar.
2 In
clud
es p
atie
nts
switc
hed
to C
at.IV
bec
ause
spu
tum
sam
ple
take
n at
sta
rt of
trea
tmen
t tur
ned
out t
o be
MD
RTB
. 3
Oth
er p
revi
ousl
y tre
ated
cas
es in
clud
e pu
lmon
ary
case
s w
ith u
nkno
wn
hist
ory
of p
revi
ous
treat
men
t, pr
evio
usly
trea
ted
sput
um s
mea
r mic
rosc
opy
nega
tive
pulm
onar
y ca
ses,
an
d pr
evio
usly
trea
ted
extra
pulm
onar
y ca
ses.
‘Tra
nsfe
rred
in’ a
nd c
hron
ic c
ases
are
exc
lude
d.
4 In
clud
es T
B p
atie
nts
cont
inui
ng o
n C
PT
star
ted
befo
re T
B d
iagn
osis
and
thos
e st
arte
d du
ring
TB tr
eatm
ent (
till l
ast d
ay o
f TB
trea
tmen
t).
5 In
clud
es T
B p
atie
nts
cont
inui
ng o
n A
RT
star
ted
befo
re T
B d
iagn
osis
and
thos
e st
arte
d du
ring
TB t
reat
men
t (til
l las
t day
of T
B tr
eatm
ent).
24
Form
7, Q
uart
erly
Rep
ort o
n TB
Tre
atm
ent O
utco
me
and
TB/H
IV A
ctiv
ities
in B
MU
A
dded
dat
a (c
ircle
d in
blu
e) a
nd ju
stifi
catio
n:
• "B
asic
Man
agem
ent U
nit"
is a
dded
in th
e tit
le a
ccor
ding
to th
e de
finiti
on in
the
Com
pend
ium
of i
ndic
ator
s fo
r mon
itorin
g an
d ev
alua
ting
natio
nal
tube
rcul
osis
pro
gram
s (W
HO
/HTM
/TB
/200
4.34
4), p
age
10.
• D
eliv
ery
of C
PT
and
AR
T fo
r HIV
-pos
itive
TB
pat
ient
s an
d co
rres
pond
ing
foot
note
are
add
ed o
n th
is fo
rm.
Mod
ified
dat
a (c
ircle
d in
blu
e) a
nd ju
stifi
catio
n:
• S
mea
r (+)
and
sm
ear (
–) a
re s
pelt
out a
s sp
utum
sm
ear m
icro
scop
y po
sitiv
e an
d sp
utum
sm
ear m
icro
scop
y ne
gativ
e fo
r bet
ter c
onsi
sten
cy.
• Th
e th
ree
sepa
rate
trea
tmen
t out
com
es fo
r Rel
apse
, Tre
atm
ent a
fter f
ailu
re a
nd T
reat
men
t afte
r def
ault
are
grou
ped
into
one
out
com
e fo
r pr
evio
usly
trea
ted
sput
um s
mea
r mic
rosc
opy
posi
tive
case
s. T
his
grou
ping
is m
ore
spec
ific
beca
use
it ex
clud
es p
revi
ousl
y tre
ated
spu
tum
sm
ear
mic
rosc
opy
nega
tive
or s
putu
m s
mea
r mic
rosc
opy
not d
one,
and
pre
viou
sly
treat
ed e
xtra
pulm
onar
y TB
cas
es. T
he c
urre
nt b
reak
dow
n of
pr
evio
usly
trea
ted
case
s is
ofte
n no
t fille
d ou
t at t
he d
istri
ct/B
MU
leve
l due
to li
mite
d nu
mbe
r of p
revi
ousl
y tre
ated
cas
es p
er b
reak
dow
n an
d is
not
of
ten
anal
ysed
. •
Trea
tmen
t out
com
es fo
r spu
tum
sm
ear m
icro
scop
y ne
gativ
e TB
cas
es a
re g
roup
ed w
ith e
xtra
pulm
onar
y an
d ot
her p
revi
ousl
y tre
ated
TB
case
s.
This
is s
een
as a
n im
porta
nt in
dica
tor f
or m
onito
ring
the
impa
ct o
f HIV
on
TB.
R
emov
ed d
ata
(circ
led
in re
d in
ann
ex 8
, pag
e 66
) and
just
ifica
tion:
non
e N
ote:
HIV
test
ing
is re
porte
d on
ly o
nce
in th
e Q
uarte
rly R
epor
t on
TB C
ase
Reg
istra
tion
follo
win
g th
e re
com
men
ded
stra
tegy
to te
st T
B c
ases
bef
ore
TB
treat
men
t sta
rts (e
vent
ually
am
ong
TB s
uspe
cts
or b
efor
e be
ing
refe
rred
to fa
cilit
ies
with
cap
acity
to d
iagn
ose
TB).
Tuberculosis Programme Form 8
25
Quarterly Order Form for TB Drugs with Patient Kits in Basic Management Unit
Forms to be adapted according to the national treatment regimen, and available patient kits
Name of BMU: ____________________ Facility: ___________
Name and signature: _________________________________
_____ quarter of year______
Date of completion of this form: ______________________________
Block 1: Patient kits of anti-TB drugs (for adult patients)--needs based on morbidity (case notification)
Kit
A
No. of cases 1
B Required
buffer stock B = A
C Stock of new kits on last
day of previous quarter
D Stock of
repackaged kits on last day
of previous quarter
E
Number of kits to order
E = A+B-C-D
Kit1 and 3: 2(RHZE)/4(RH)
Kit2: 2S(RHZE)/1(RHZE)/5(RHE)
Other kit Block 2: Anti-TB drugs tablets for children (0-14 yrs)--needs based on morbidity (case notification)
Drug /unit tablets (1)
Paediatric 2(RHZ)/4(RH)
(2) Required
buffer stock
(3) Stock last day
previous quarter
(4) Total order
Case 1 Factor 2 Total (1) (2) = (1) (3) (4) = (1) + (2) - (3)
(R60/H30/Z150) X 168
(R60/H30) X 336 Block 3: Other anti-TB drugs and items 3--needs based on consumption
Drug / item Specify drug strength
Unit
(a) Average quarterly
consumption based on last year’s consumption
(b) Required buffer
stock (b) = (a)
(c) Stock in tablets/
vials/items on last day previous
quarter
(d) Number
tablets/items to order
(d) = (a) + (b) - (c)
1 Enter the number of cases enrolled in the previous quarter (from the Quarterly Report on TB Case Registration). 2 Factors are proposed by GDF and can be adapted at country level. 3 Depending on the TB control treatment policy, you may need to add paediatric anti-TB drugs (E100, Z150, H50); loose tablets of
individual anti-TB drugs for side-effect management; isoniazid for preventive therapy for children and for PLWHA; co-trimoxazole for HIV-positive TB patients; ART for HIV+TB patients; items such as TB Register and forms, HIV test kits, etc.
Tube
rcul
osis
Pro
gram
me
Fo
rm 8
A
26
Q
uart
erly
Ord
er F
orm
for T
B D
rugs
with
Blis
ters
and
Uni
t Tab
lets
/Via
ls in
BM
U
Form
s to
be
adap
ted
at c
ount
ry le
vel a
ccor
ding
to th
e na
tiona
l tre
atm
ent r
egim
en, a
nd a
vaila
ble
blis
ters
follo
win
g W
HO
reco
mm
ende
d re
gim
en
Nam
e of
BM
U:
____
____
____
____
____
Fac
ility
: ___
____
____
____
____
_
Nam
e an
d si
gnat
ure:
___
____
____
____
____
____
____
____
____
____
___
__
___
quar
ter o
f yea
r___
____
Dat
e of
com
plet
ion
of th
is fo
rm:
____
____
____
____
____
____
____
____
____
Blo
ck 1
: Ant
i-TB
dru
gs b
liste
rs a
nd u
nit t
able
ts/v
ials
--nee
ds b
ased
on
mor
bidi
ty (c
ase
notif
icat
ion)
Dru
g A
Cat
I an
d III
: 2(
RH
ZE)/4
(RH
)
B C
at II
: 2(
RH
ZE)S
/1(R
HZE
)/5(R
HE
)
C
Pae
diat
ric (0
-14
yrs)
2(
RH
Z)/4
(RH
)
D
Req
uire
men
t of
last
qua
rter
E R
equi
red
buffe
r st
ock
F St
ock
last
da
y pr
evio
us
quar
ter
G
Tota
l ord
er
C
ases
To
tal
A 1
Fact
or
2C
ases
1Fa
ctor
2To
tal
B C
ases
1Fa
ctor
2
Tota
l C
D
= A
+B+C
E
=D
F G
=D+E
- F
Blis
ters
3
(R15
0/H
75/Z
400/
E27
5)
X 6
X
9
(R15
0/H
75)
X
12
(R
150/
H75
/E27
5)
X15
U
nit t
able
ts/v
ials
S
1g
X56
S
yrin
ges
need
les
X
56
Wat
er fo
r inj
ectio
n
X56
(R
60/H
30/Z
150)
X16
8(R
60/H
30)
X
336
Blo
ck 2
: Oth
er a
nti-T
B d
rugs
and
item
s 4 --n
eeds
bas
ed o
n co
nsum
ptio
n
Dru
g / i
tem
S
peci
fy d
rug
stre
ngth
U
nit
(a)
Ave
rage
qua
rterly
con
sum
ptio
n ba
sed
on la
st y
ear’s
con
sum
ptio
n
(b)
Req
uire
d bu
ffer
stoc
k
(c)
Stoc
k in
tabl
ets/
vial
s/ite
ms
last
day
pre
viou
s qu
arte
r
(d)
No.
of t
able
ts/it
ems
to o
rder
(d
) = (a
) + (b
) - (c
)
1
Ent
er th
e nu
mbe
r of c
ases
enr
olle
d in
the
prev
ious
qua
rter (
from
the
Qua
rterly
Rep
ort o
n TB
Cas
e R
egis
tratio
n).
2 F
acto
r for
blis
ters
and
tabl
ets
are
prop
osed
by
GD
F an
d ca
n be
ada
pted
at c
ount
ry le
vel.
3 B
liste
r of 2
8 ta
blet
s.
4 D
epen
ding
on
the
TB c
ontro
l tre
atm
ent p
olic
y, y
ou m
ay n
eed
to a
dd p
aedi
atric
ant
i-TB
dru
gs (E
100,
Z15
0, H
50);
loos
e ta
blet
s of
indi
vidu
al a
nti-T
B d
rugs
for s
ide-
effe
ct m
anag
emen
t; is
onia
zid
for
prev
entiv
e th
erap
y fo
r chi
ldre
n an
d fo
r PLW
HA
; co-
trim
oxaz
ole
for H
IV-p
ositi
ve T
B p
atie
nts;
AR
T fo
r HIV
+TB
pat
ient
s; it
ems
such
as
TB R
egis
ter a
nd fo
rms,
HIV
test
kits
, etc
.
Tube
rcul
osis
Pro
gram
me
Fo
rm 8
B
27
Qua
rter
ly O
rder
For
m fo
r TB
Dru
gs w
ith U
nit T
able
ts/v
ials
in B
MU
Fo
rms
to b
e ad
apte
d ac
cord
ing
to th
e na
tiona
l tre
atm
ent r
egim
en, a
nd a
vaila
ble
unit
tabl
ets/
vial
s fo
llow
ing
WH
O re
com
men
ded
regi
men
N
ame
of B
MU
: __
____
____
____
____
__ F
acili
ty: _
____
____
____
____
__
N
ame
and
sign
atur
e: _
____
____
____
____
____
____
____
____
____
____
__
___
quar
ter o
f yea
r___
___
D
ate
of c
ompl
etio
n of
this
form
: __
____
____
____
____
____
____
____
____
B
lock
1: A
nti-T
B d
rugs
uni
ts--n
eeds
bas
ed o
n m
orbi
dity
(cas
e no
tific
atio
n)
Dru
g / I
tem
A
Cat
I an
d III
: 2(
RH
ZE)/4
(RH
)
B C
at II
: 2(
RH
ZE)S
/1(R
HZE
)/5(R
HE
)
C
Pae
diat
ric (0
-14
yrs)
2(
RH
Z)/4
(RH
)
D
Req
uire
men
tof
last
qu
arte
r
E R
equi
red
buffe
r st
ock
F St
ock
last
da
y pr
evio
us
quar
ter
G
Tota
l ord
er
C
ases
1Fa
ctor
2To
tal
A C
ases
1Fa
ctor
2To
tal
B C
ases
1Fa
ctor
2To
tal
CD
= A
+B+C
E=D
F
G=D
+E -
F U
nit t
able
ts/v
ials
(R
150/
H75
/Z40
0/E
275)
X16
8
X
252
(R15
0/H
75)
X
336
(R15
0/H
75/E
275)
X
420
S1g
X
56
Syr
inge
s ne
edle
s
X56
W
ater
for i
njec
tion
X
56
(R60
/H30
/Z15
0)
X
168
(R60
/H30
)
X33
6
B
lock
2: O
ther
ant
i-TB
dru
gs a
nd it
ems
3 --nee
ds b
ased
on
cons
umpt
ion
Dru
g / i
tem
S
peci
fy d
rug
stre
ngth
U
nit
(a)
Ave
rage
qua
rterly
con
sum
ptio
n ba
sed
on la
st y
ear’s
con
sum
ptio
n
(b)
Req
uire
d bu
ffer
stoc
k (b
) = (a
)
(c)
Sto
ck in
tabl
ets/
via
ls/it
ems
last
day
pre
viou
s qu
arte
r
(d)
No.
of t
able
ts/it
ems
to o
rder
(d
) = (a
)+ (b
) - (c
)
1
Ent
er th
e nu
mbe
r of c
ases
enr
olle
d in
the
prev
ious
qua
rter (
from
the
Qua
rterly
Rep
ort o
n TB
Cas
e R
egis
tratio
n).
2 F
acto
rs a
re p
ropo
sed
by G
DF
and
can
be a
dapt
ed a
t cou
ntry
leve
l.
3 D
epen
ding
on
the
TB c
ontro
l tre
atm
ent p
olic
y, y
ou m
ay n
eed
to a
dd p
aedi
atric
ant
i-TB
dru
gs (E
100,
Z15
0, H
50);
loos
e ta
blet
s of
indi
vidu
al a
nti-T
B d
rugs
for s
ide-
effe
ct m
anag
emen
t; is
onia
zid
for
prev
entiv
e th
erap
y fo
r chi
ldre
n an
d fo
r PLW
HA
; co-
trim
oxaz
ole
for H
IV-p
ositi
ve T
B p
atie
nts;
AR
T fo
r HIV
-pos
itive
TB
pat
ient
s; it
ems
such
as
TB R
egis
ter a
nd fo
rms,
HIV
test
kits
, etc
.
28
Form
8, 8
A, 8
B, Q
uart
erly
Ord
er F
orm
for T
B D
rugs
with
Pat
ient
s K
it, B
liste
rs o
r Uni
t Tab
lets
/via
ls
Add
ed d
ata
(circ
led
in b
lue)
and
just
ifica
tion:
•
Thes
e th
ree
form
s ar
e de
velo
ped
base
d on
the
rem
oved
WH
O Q
uarte
rly R
epor
ts o
n P
rogr
amm
e M
anag
emen
t (A
, B, C
) and
on
the
Uni
on Q
uarte
rly
Ord
er fo
rms.
The
sam
e pr
inci
ples
app
ly to
thes
e fo
rms,
suc
h as
the
mor
bidi
ty c
alcu
latio
n (p
revi
ous
case
not
ifica
tion)
rath
er th
an c
onsu
mpt
ion
(pre
viou
s qu
antit
ies
used
), bu
ffer s
tock
equ
ival
ent t
o re
quire
men
t, an
d us
e of
a p
ull s
yste
m (b
otto
m-u
p or
der)
rath
er th
an p
ush
syst
em (t
op-d
own
appr
oach
). Th
e th
ree
optio
ns a
re p
rese
nted
acc
ordi
ng to
the
anti-
TB d
rug
pres
enta
tion
in p
atie
nt k
its (8
), bl
iste
rs (8
A) o
r tab
let/v
ial u
nits
(8 B
). O
pen
patie
nt k
its a
re re
pack
aged
at t
he B
MU
leve
l. •
Pae
diat
ric s
treng
th a
nd fo
rmul
atio
n ar
e ad
ded
base
d on
the
paed
iatri
c tre
atm
ent m
ost c
omm
only
use
d 2(
RH
Z)/4
(RH
).
• Th
e fa
ctor
s us
ed in
eac
h fo
rm a
re b
ased
on
GD
F cr
iteria
and
cou
ld b
e ad
apte
d to
cou
ntrie
s w
here
ave
rage
wei
ght i
s hi
gher
. •
Add
ition
al fo
rms
coul
d be
dev
elop
ed fo
r the
inte
rmed
iate
leve
l bas
ed o
n th
e sa
me
stru
ctur
e.
Mod
ified
dat
a (c
ircle
d in
blu
e) a
nd ju
stifi
catio
n: n
one
R
emov
ed d
ata
(circ
led
in re
d in
ann
ex 9
, pag
e 67
) and
just
ifica
tion:
•
Qua
rterly
repo
rts o
n pr
ogra
mm
e m
anag
emen
t (A
, B, C
) wer
e re
mov
ed d
ue to
lim
ited
upta
ke b
y co
untri
es.
Tube
rcul
osis
Pro
gram
me
Fo
rm 9
Qua
rter
ly O
rder
For
m fo
r Lab
orat
ory
Supp
lies
in B
asic
Man
agem
ent U
nit
Labo
rato
ry s
uppl
y or
ders
are
pre
pare
d ev
ery
3 m
onth
s w
ith n
eeds
bas
ed o
n co
nsum
ptio
n N
ame
of B
MU
: __
____
____
____
____
__ F
acili
ty: _
____
____
____
____
____
_
Nam
e an
d si
gnat
ure:
___
____
____
____
____
____
____
____
____
____
____
_
__
___
quar
ter o
f yea
r___
___
D
ate
of c
ompl
etio
n of
this
form
: __
____
____
____
____
____
____
____
____
Labo
rato
ry it
ems
Mea
sure
men
t un
it
(a)
Ave
rage
qua
rterly
co
nsum
ptio
n1
(b)
Req
uire
d bu
ffer s
tock
(b
) = (a
)
(c)
Sto
ck in
uni
t las
t day
pr
evio
us q
uarte
r
(d)
No.
of u
nits
to o
rder
(d
) = (a
)+ (b
) - (c
) Ba
sic
fuch
sin
M
ethy
lene
blue
Im
mer
sion
oil
S
ulph
uric
acid
P
heno
l
Met
hano
l
Slid
es
S
putu
mco
ntai
ners
H
IV ra
pid
test
kit
1
H
IV c
onfir
mat
ion
test
kit
2
1 B
ased
on
the
last
yea
r con
sum
ptio
n
OR
LA
BO
RA
TOR
Y U
SIN
G P
REP
AR
ED S
OLU
TIO
N
Labo
rato
ry it
ems
Mea
sure
men
t un
it
(a)
Ave
rage
qua
rterly
co
nsum
ptio
n1
(b)
Req
uire
d bu
ffer s
tock
(b
) = (a
)
(c)
Sto
ck in
uni
t las
t day
pr
evio
us q
uarte
r
(d)
Num
ber u
nit t
o or
der
(d) =
(a)+
(b) -
(c)
Sta
inin
gso
lutio
n
Dec
olou
ratio
nso
lutio
n
Cou
nter
stai
ning
solu
tion
Im
mer
sion
oil
S
lides
Spu
tum
cont
aine
rs
HIV
rapi
d te
st k
it 1
H
IV c
onfir
mat
ion
test
kit
2
29
1 B
ased
on
the
last
yea
r’s c
onsu
mpt
ion
30
Form
9, Q
uart
erly
Ord
er F
orm
for L
abor
ator
y Su
pplie
s A
dded
dat
a (c
ircle
d in
blu
e) a
nd ju
stifi
catio
n:
• Th
is fo
rm w
as d
evel
oped
bas
ed o
n th
e re
mov
ed W
HO
Qua
rterly
Rep
orts
on
Pro
gram
me
Man
agem
ent (
A, B
, C).
The
calc
ulat
ion
of th
e or
der i
s ba
sed
on c
onsu
mpt
ion
(pre
viou
s qu
antit
ies
used
) rat
her t
han
mor
bidi
ty (p
revi
ous
num
ber o
f TB
cas
es),
buffe
r sto
ck e
quiv
alen
t to
cons
umpt
ion,
pu
ll sy
stem
(bot
tom
-up
orde
r) ra
ther
than
pus
h sy
stem
(top
-dow
n ap
proa
ch).
The
two
optio
ns a
re p
rese
nted
acc
ordi
ng to
the
reag
ent
pres
enta
tion.
•
Add
ition
al fo
rms
coul
d be
dev
elop
ed fo
r the
inte
rmed
iate
leve
l bas
ed o
n th
e sa
me
stru
ctur
e.
Mod
ified
dat
a (c
ircle
d in
blu
e) a
nd ju
stifi
catio
n: n
one
R
emov
ed d
ata
(circ
led
in re
d in
ann
ex 9
pag
e 67
) and
just
ifica
tion:
Q
uarte
rly R
epor
t on
Pro
gram
me
Man
agem
ent (
A, B
, C).
Tube
rcul
osis
Pro
gram
me
Fo
rm 1
0
31
Year
ly R
epor
t on
Prog
ram
me
Man
agem
ent i
n B
asic
Man
agem
ent U
nit
Nam
e of
BM
U:
____
____
____
____
____
Fac
ility
: ___
____
____
Yea
r:___
___
Dat
e of
com
plet
ion
of th
is fo
rm: _
____
__ S
igna
ture
: ___
____
____
____
_ B
lock
1: H
ealth
car
e fa
cilit
ies/
prov
ider
s in
volv
ed in
TB
con
trol
Fa
cilit
ies
prov
idin
g an
y TB
con
trol s
ervi
ces
3Fa
cilit
ies
with
labo
rato
ry fa
cilit
ies
Faci
litie
s pr
ovid
ing
HIV
ser
vice
s Fa
cilit
y/pr
ovid
er
type
1
Tota
l nu
mbe
r of
fa
cilit
ies
in th
e B
MU
2
(a)
Targ
et
cum
ulat
ive
num
ber t
o in
volv
e3
(b)
Cum
ulat
ive
num
ber
actu
ally
in
volv
ed
(c)
Targ
et c
umul
ativ
e N
o. to
invo
lve
in
sput
um s
mea
r m
iicro
scop
y4
(d)
Cum
ulat
ive
No.
in
volv
ed in
sp
utum
sm
ear
mic
rosc
opy
(e)
Out
of (
e), N
o.
invo
lved
in
Lab.
Qua
lity
Assu
ranc
e (f)
Out
of (
e), N
o.
prov
idin
g cu
lture
ser
vice
s(g
)
Out
of (
e)
No.
prov
idin
g
DS
T
serv
ices
(h
)
Out
of (
c), N
o.
prov
idin
g H
IV te
stin
g &
cou
nsel
. to
all T
B
patie
nts
(i)
Out
of (
c)
No.
pro
vidi
ng
AR
T to
TB
pa
tient
s
(j)
Pu
blic
faci
lity
Priv
ate
faci
lity/
prov
ider
Oth
ers
5
B
lock
2: C
ontr
ibut
ion
by h
ealth
car
e fa
cilit
ies/
pro
vide
rs in
TB
con
trol
Blo
ck 3
: Con
trib
utio
n by
trai
ned
and
supe
rvis
ed c
omm
unity
in
TB
con
trol
11
No.
of
new
spu
tum
sm
ear m
icro
scop
y po
sitiv
e ca
ses
diag
nose
d in
a y
ear
No.
of n
ew s
putu
m s
mea
r m
icro
scop
y po
sitiv
e ca
ses
star
ted
on tr
eatm
ent i
n ye
ar
TOTA
L 6,
7
Fa
cilit
y /p
rovi
der t
ype1
Ref
erre
d by
8D
iagn
osed
by
9Tr
eate
d by
10
Sel
f-ref
erra
l
Pub
lic fa
cilit
y
Priv
ate
faci
lity
/pro
vide
r
Oth
ers
No.
new
spu
tum
sm
ear
mic
rosc
opy
posi
tive
case
s re
ferre
d by
the
com
mun
ity
No.
new
spu
tum
sm
ear
mic
rosc
opy
posi
tive
case
s re
ceiv
ing
treat
men
t sup
port
by
the
com
mun
ity
1 H
ealth
faci
lity
is d
efin
ed a
s an
y he
alth
inst
itutio
n w
ith h
ealth
car
e pr
ovid
ers
form
ally
eng
aged
in a
ny o
f the
follo
win
g TB
con
trol f
unct
ions
(DO
TS):
refe
rring
TB
sus
pect
s/ca
ses,
la
bora
tory
dia
gnos
is, T
B tr
eatm
ent a
nd p
atie
nt s
uppo
rt du
ring
treat
men
t. Fa
cilit
y ty
pes
are
indi
cativ
e, c
onsi
sten
t with
the
refe
rral
box
of t
he T
B T
reat
men
t Car
d an
d sh
ould
be
adap
ted
to lo
cal c
onte
xt.
2 K
now
n nu
mbe
r of e
xist
ing
faci
litie
s (p
rovi
der)
in th
e B
MU
. The
tabl
e m
ay b
e ad
apte
d w
ith m
ore
row
s to
inco
rpor
ate
faci
litie
s th
at a
re re
leva
nt fo
r the
cou
ntry
. 3
Faci
litie
s (p
rovi
ders
) for
mal
ly e
ngag
ed in
any
of t
he fo
llow
ing
TB c
ontro
l fun
ctio
ns (D
OTS
): re
ferri
ng T
B s
uspe
cts/
case
s, la
bora
tory
dia
gnos
is, T
B tre
atm
ent a
nd p
atie
nt s
uppo
rt du
ring
treat
men
t. 4
Th
e cu
mul
ativ
e nu
mbe
r of f
acili
ties
(pro
vide
rs) t
hat w
as p
lann
ed to
be
invo
lved
in th
e ye
ar o
f the
repo
rt.
5 O
ther
cat
egor
ies
may
incl
ude
PH
C fa
cilit
y, m
edic
al c
olle
ge, p
rivat
e N
GO
hos
pita
l, pr
ivat
e N
GO
clin
ic, p
rivat
e pr
actit
ione
rs, c
orpo
rate
hea
lth fa
cilit
ies,
pris
on h
ealth
ser
vice
, arm
y he
alth
faci
litie
s, p
harm
acie
s, tr
aditi
onal
hea
lers
, etc
. 6
Tota
l num
ber o
f new
sm
ear p
ositi
ve p
atie
nts
diag
nose
d an
d re
cord
ed in
the
TB L
abor
ator
y R
egis
ter f
or th
e ye
ar.
7 To
tal n
umbe
r of n
ew s
mea
r pos
itive
pat
ient
s re
cord
ed in
the
BM
U T
B R
egis
ter f
or th
e ye
ar.
8 N
ew s
mea
r pos
itive
cas
es re
ferre
d fo
r dia
gnos
is b
y ea
ch fa
cilit
y/pr
ovid
er c
ateg
ory,
as
reco
rded
in th
e co
lum
n fo
r "na
me
of re
ferri
ng h
ealth
faci
lity"
in th
e TB
Lab
orat
ory
Reg
iste
r. 9
New
sm
ear p
ositi
ve c
ases
dia
gnos
ed b
y ea
ch fa
cilit
y/pr
ovid
er c
ateg
ory
reco
rded
in th
e TB
Lab
orat
ory
Reg
iste
r of t
he fa
cilit
y/pr
ovid
er o
f mic
rosc
opy
serv
ice.
10
New
spu
tum
sm
ear p
ositi
ve c
ases
trea
ted
by re
spec
tive
prov
ider
cat
egor
y, a
s re
cord
ed in
the
colu
mn
"hea
lth fa
cilit
y" in
the
BM
U T
B R
egis
ter.
11 T
his
bloc
k is
fille
d ba
sed
on th
e in
divi
dual
TB
Tre
atm
ent C
ard
(refe
rral b
ox, n
ame
of tr
eatm
ent s
uppo
rter)
or fr
om th
e TB
Reg
iste
r (fo
rm D
of t
he a
dditi
onal
TB
dat
a -p
art 3
).
Com
mun
ity is
def
ined
as
train
ed a
nd re
gula
rly s
uper
vise
d in
form
al p
ract
ition
ers,
com
mun
ity w
orke
r/vol
unte
er, f
amily
mem
bers
, frie
nds
prov
idin
g se
rvic
es o
utsi
de a
faci
lity
(hea
lth
inst
itutio
n).
Not
e: T
his
form
cou
ld b
e fil
led
only
for s
elec
ted
perio
d of
tim
e an
d fo
r sel
ecte
d B
MU
.
Tube
rcul
osis
Pro
gram
me
For
m 1
0 (c
ontin
ued)
32
Blo
ck 4
: Sta
ff po
sitio
n an
d tr
aini
ng 1
Cat
egor
y of
sta
ff in
volv
ed in
NTP
2N
umbe
r of p
ositi
ons
esta
blis
hed/
san
ctio
ned
3 (a
)O
f the
m (a
), nu
mbe
r of
posi
tions
fille
d O
f the
m (a
), nu
mbe
r tra
ined
in N
TP
in th
e pa
st 1
2 m
onth
s 4
Tota
l tra
ined
in N
TP
A. A
LL H
EALT
H F
AC
ILIT
IES
M
edic
al O
ffice
r
R
egis
tere
d N
urse
/Reg
iste
red
Mid
wife
/Enr
olle
d N
urse
/Enr
olle
d M
idw
ife
Hea
lth A
ssis
tant
/Med
ical
A
ssis
tant
/Clin
ical
Offi
cer
Labo
rato
ry T
echn
icia
n/ M
icro
scop
ist
Phar
mac
ist
Cou
nsel
lor
Oth
er c
ateg
orie
s (s
peci
fy) 5
B. B
MU
LEV
EL
BM
U T
B C
oord
inat
or
BM
U T
B/H
IV C
oord
inat
or
BM
U L
abor
ator
y S
uper
viso
r
B
MU
Sup
ervi
sor
BM
U D
rug
Sto
re M
anag
er
Stat
istic
al A
ssis
tant
O
ther
cat
egor
ies
(spe
cify
)
1 H
ealth
faci
lity
to fi
ll in
sec
tion
A; B
MU
Lev
el to
fill
in S
ectio
n A
with
cum
ulat
ive
data
for a
ll he
alth
faci
litie
s in
BM
U p
lus
BM
U (d
istri
ct)-s
peci
fic p
ositi
ons.
2
Incl
udin
g pr
ivat
e pr
ovid
ers,
com
mun
ity w
orke
rs, e
tc.
3 P
art t
ime
post
s ar
e co
nsid
ered
as
one
posi
tion.
4
Trai
ned
in N
TP is
def
ined
as
havi
ng a
ttend
ed a
sta
ndar
dize
d co
mpe
tenc
y (s
kills
)-bas
ed tr
aini
ng c
ours
e de
sign
ed b
y N
TP fo
r the
spe
cific
job
func
tions
acc
ordi
ng to
the
NTP
man
ual.
5 If
TB-H
IV c
olla
bora
tive
activ
ities
are
par
t of N
TP, a
dd a
dditi
onal
sta
ff ca
tego
ries
as re
leva
nt b
ased
on
job
func
tions
.
Not
e •
Sim
ilar f
orm
for P
rovi
ncia
l Lev
el s
houl
d be
fille
d w
ith c
umul
ativ
e da
ta fo
r all
heal
th fa
cilit
ies
in p
rovi
nce,
Sec
tion
B w
ith c
umul
ativ
e da
ta fo
r all
BM
U in
pro
vinc
e pl
us
prov
ince
-spe
cific
pos
ition
s.
• S
imila
r for
m fo
r Cen
tral L
evel
sho
uld
be fi
lled
with
cum
ulat
ive
data
for a
ll he
alth
faci
litie
s in
cou
ntry
, Sec
tion
B w
ith c
umul
ativ
e da
ta fo
r all
BM
U in
cou
ntry
plu
s ce
ntra
l -sp
ecifi
c po
sitio
ns.
33
Form 10, Yearly Report of Programme Management in BMU Added data (circled in blue) and justification:
• The yearly report is a new programme management tool that allows monitoring of components 3, 4 and 5 of the Stop TB Strategy, especially − engage all care providers: sub-component public-public, and public-private mix
approaches (block 1 and 2); − empower people with TB and communities: sub-component community participation
in TB care (block 3); and − contribute to health system strengthening: sub-component improve human resources
(block 4). • Filling in this new form requires extensive initial and on-site training and perhaps phased
implementation. • Block 1, 2 and 3 could be collected from all or selected BMUs for the whole year or for a
selected quarter. Data for block 4 on human resources should be collected on a routine basis in all BMU. A similar form could be used for provincial and central levels with cumulative aggregated data.
• Block 1 monitors the process of involving relevant health-care providers formally engaged in any of the following TB control functions (DOTS): referring TB suspects/cases, laboratory diagnosis, TB treatment and patient support during treatment; and in collaborative TB/HIV activities and MDRTB-related activities. In order to accurately fill the form, mapping of existing health facilities is required at the beginning of the reporting year. Furthermore, ased on the mapping, targets should be set for the number of health facilities of different categories to involve. Finally, BMU managers need to keep a log of activities concerning the involvement of different health-care providers.
• Block 2 provides data on the relative contribution by different health-care providers to case detection (referral and diagnosis) and treatment under DOTS. Block 2 is thus closely linked to Block 1. TB Laboratory Register and BMU TB Register will generate the data required to complete this block.
• Block 3 provides data on the relative contribution by the community to case detection (referral for diagnosis) and treatment support. The TB Treatment Card (box on community for referral and treatment supporter’s name) or BMU TB Register (see additional columns on community in form V part II or form D part III) will generate the data required to complete this block.
• Block 4 aims to monitor that different types of staff at the BMU have the skills, knowledge and attitudes necessary (in other words are competent) to successfully implement and sustain TB control activities, and that sufficient numbers of staff of all categories involved in TB control (clinical and managerial) exist at all levels.
Modified data (circled in blue) and justification: none Removed data (circled in red) and justification: none
Tuberculos
is Programme Form 11
34
1 Referral oving a TB patient in a for the purpose of start of treatment (treatment closer to patient’s home). T ng a "referred" patient is responsible to inform the facility sending the patient about the care provided. 2 Transfer is the process of moving between 2 BMU a TB istered in a BMU TB Register to continue his treatment in another area with a different BMU TB Register transferring-out' a patient is responsible to report the treatment outcome, after getting the informati eting the treatment. The BMU receiving a patient 'transferred-in' is responsible for inform ding the patient 1) of the arrival of the patient and 2) at the end of the treatment, of the treatment o Note: A facility referring or transferring large numbers patients such as large hospitals may use separate forms for referral and transfer and may have a specific register rrals.
*CAT I, II, III
Other (CPT, ART etc) :
(For Transfer) BMU TB Register No. _______________ Date TB treatment started: ________________
Diagnosis:___________________________________________________________________________
___________________________________________________________________________________
Address of patient (if moving, future address): ______________________________________________
Name of patient ___________________________________________ Age ________ Sex: M F
To receiving facility: _____________________________ Receiving BMU ________________
From sending facility: ____________________________ Sending BMU __________________
Name/address of referring/transferring facility
Name / signature of person sending the patient _____________________________________________
Remarks (e.g. side-effects observed): ____________________________________________________
___________________________________________________________________________________
_
Tuberculosis Treatment Referral/Transfer
(Complete top part in triplicate)
Tick for this referral or transfer: Referral1 or Transfer2 Date of referral/ transfer __________
Drugs patient is receiving _______________________________________________________________
Return this part to facility sending referred / transferred patient as soon as patient has reported. Name / signature of person receiving the patient ___________________________ Date ____________
The above patient reported at this facility on __________________________________________ (date)
BMU TB Register No. ___________ Name of patient ______________________________________
BMU ______________________________ Facility _________________________________________
Documented evidence of HIV tests (and results) during or before TB treatment should be reported.
is th
For use by facility receiving referred / transferred patient
e process of m prior to registration BMU TB Registerhe BMU receivi
patient reg. The BMU '
on from the BMU compling the BMU sen
utcome.
of for refe
Form 11, Tuberculosis Treatment Referral/Transfer Added data (circled in blue) and justification:
• Definition of Transfer and Referral is added in each form to clarify the difference and improve the respective follow-up for the related tasks.
• Box is added on other treatment such as ART or CPT. • Name of person sending and receiving the patient is added to improve the follow-up.
Modified data (circled in blue) and justification:
• Sending and receiving BMU / facilities are presented more explicitly. • Category of treatment is presented in more concise way. • BMU replaces District.
Removed data (circled in red in annex 10, page 71) and justification: • Reason for transfer/referral is included in its definition.
35
36
Revised TB recording and reporting forms and registers
3. Part II: Essential TB data in basic management unit using routine culture
Additional or modified data are circled in blue in each form: Removed data are circled in a red dashed line in the current set of forms (annexes, pages 56-71).
Rationale for changes related to use of culture seen in the following forms:
− Although high-quality sputum smear microscopy remains the cornerstone for case detection and TB control in general, culture and drug susceptibility tests (DST) are increasingly important and necessary to test re-treatment cases, patients with suspected drug-resistant TB, and sputum smear microscopy negative cases when indicated. In many settings culture and DST services are being introduced in a phased manner at appropriate referral levels of the health system. To conform to the Stop TB Strategy, in order of priority and depending on available laboratory capacity, culture and DST should be routinely used to monitor drug-resistant TB, including periodical testing related to drug resistance prevalence surveys, to diagnose drug-resistant TB, to diagnose sputum smear microscopy negative TB and to diagnose TB among HIV-positive patients and children.
− The emergence of resistance to drugs used to treat TB, and particularly MDR-TB, has
become a significant public health problem in a growing number of countries and an obstacle to effective TB control. In countries where drug resistance has been identified, specific measures need to be taken within the TB control programme to address the problem through appropriate management of patients. Culture and DST have already been introduced as routine diagnostic procedures in several settings with a high burden of MDRTB.
− In high HIV prevalence countries, the incidence of sputum smear microscopy negative TB
has increased substantially. There is need for improved diagnosis of sputum smear microscopy negative TB. In countries with suitable infrastructure and laboratory capacity, culture and indicated DST can contribute to this.
The revised forms and registers for settings with routine culture and DST services will facilitate the monitoring of the use of culture and DST in these settings. The use of these forms is increasingly important in settings with a high burden of MDRTB. In principle the forms are the same as presented in the previous chapter. The added data are the same for all data outside culture and DST. For settings routinely performing culture, relevant data elements for culture and DST have been added. Recording of laboratory results for cultures follows the recommendations of the Stop TB Working Group on DOTS Expansion / laboratory strengthening sub-group including recording and reporting of those cultures which become contaminated. Recording of drug susceptibility results also follows the international recommendations of the laboratory strengthening capacity sub-group. Given the variability of second-line drug susceptibility testing, only results from first-line anti-TB drugs are recorded here. The Quarterly Report on TB Case Registration in BMU using Routine Culture records age and sputum smear microscopy breakdown by positive and negative culture status. This will facilitate the recording and reporting of sputum smear microscopy negative, culture positive TB cases, as well as those TB cases where the culture is negative. The Quarterly Report on TB Treatment Outcome and TB/HIV Activities in BMU using Routine Culture will facilitate the evaluation of outcome by culture status; note that culture not done is grouped with negative culture. It also measures the number of TB suspects with a positive culture, and allows measurement of treatment outcomes for some key sputum smear microscopy and culture combinations. The Quarterly Order Form for Culture and DST Laboratory Supplies in Basic Management Unit captures the laboratory needs to perform cultures and DST for TB cases.
37
Tuberculosis Programme Form I
Request for Sputum Smear Microscopy, Culture, Drug Susceptibility Test
The completed form with results should be sent promptly by the laboratory to the referring facility
Referring facility 1: ______________________________________________ Date ________________________
Name of patient ________________________________________________ Age ________ Sex: M F
Complete patient's address _____________________________________________________________________
__________________________________________________________ _________________________________
Test(s) requested (check any that are needed):
Smear microscopy Culture Drug susceptibility testing Reason for sputum smear microscopy examination (check one):
Diagnosis
Follow-up Number of month of treatment ______ BMU TB Register number ___________ 2
Reason for culture examination: _________________________________________________________________
low-up of patients on chemotherapy
Date ________ Examined by (name and signature) _______________________________________________
R: Resistant; S: Susceptible; C: Contaminated; Nd Not done
Result (check one)
___________________________________________________________________________________________
Reason for DST: _____________________________________________________________________________
___________________________________________________________________________________________
Name and signature of person requesting examination:_______________________________________________ 1 Including all public and private health facilities/providers 2 Be sure to enter the patient’s BMU TB Register No. for fol SPUTUM SMEAR MICROSCOPY RESULTS (to be completed in laboratory)
Date 3
Sputum Laboratory Visual
4NEG 1- 9 (+) (++) (+++) collected specimen serial No. appearance
1 2 3
3 To be completed by the person collecting the sputum 4 Blood-stained, muco-purulent, saliva CULTURE RESULTS (to be completed in laboratory)
No. growth reported Neg
Fewer than 10 colonies
Exact number
10 -100 colonies (+) More than 100
colonies (+ +)
Innumerable or confluent growth (+ + +)
Result (check o
Date ______ Examined by (name and signature) _______________________________
DST RESULTS (to be completed in laboratory)
Date _________ Examined by (name and signature) ______________________________________________
38
ne) Date collected Neg (1–9 (+++)
Specimen Laboratory serial No. ) (+) (++)
Contam-inated
1 2
Date collected Specimen Pto/ Laboratory
serial No. S H R E Z Km Am Cm Ofx Eto Other 1 2
Tube
rcul
osis
Pro
gram
me
Form
II
ex /F
ge
39
B
asic
Man
agem
ent U
nit T
B L
abor
ator
y R
egis
ter f
or C
ultu
re -
Left
side
of t
he re
gist
er b
ook
Dat
e sp
ecim
en
rece
ived
Lab
seria
l nu
mbe
r
Type
of
spec
imen
re
ceiv
ed
Ref
errin
g he
alth
fa
cilit
y1P
atie
nt’s
nam
e P
atie
nt’s
add
ress
if
new
pat
ient
SM
A
Dat
e sp
ecim
en
colle
cted
Dat
e sp
ecim
en
inoc
ulat
ed
1 F
acilit
y th
at re
ferre
d (s
ent)
the
patie
nt (o
r spe
cim
en) f
or c
ultu
re. U
se s
tand
ardi
zed
type
of h
ealth
faci
litie
s ac
cord
ing
to b
lock
2 o
f the
Yea
rly R
epor
t on
Pro
gram
me
Man
agem
ent i
n B
MU
. Hea
lth fa
cilit
y is
def
ined
as
any
heal
th in
stitu
tion
with
hea
lth c
are
prov
ider
s fo
rmal
ly e
ngag
ed in
any
of t
he fo
llow
ing
TB c
ontro
l fun
ctio
ns (D
OTS
): re
ferri
ng T
B s
uspe
cts/
case
s,
labo
rato
ry d
iagn
osis
, TB
trea
tmen
t and
pat
ient
sup
port
durin
g tre
atm
ent.
Tube
rcul
osis
Pro
gram
me
Form
II (c
ontin
ued)
40
B
asic
Man
agem
ent U
nit T
B L
abor
ator
y R
egis
ter f
or C
ultu
re -
Rig
ht s
ide
of th
e re
gist
er b
ook
Rea
son
for
exam
inat
ion
Dia
gnos
is1
Follo
w-u
p2
Res
ult o
f cu
lture
3
Res
ult o
f co
nfirm
ator
y te
st fo
r M.
Tube
rcul
osis
(+
) (-)
Cul
ture
se
nt fo
r D
ST
(yes
) (no
)
Nam
e of
per
son
repo
rting
resu
ltsS
igna
ture
Dat
e cu
lture
re
sults
re
porte
d
Com
men
ts
Fo
otno
tes
appe
arin
g on
firs
t pag
e of
the
regi
ster
onl
y
1 N
ew p
atie
nts
or p
atie
nts
star
ting
a re
-trea
tmen
t reg
imen
. 2
Indi
cate
mon
ths
of tr
eatm
ent a
t whi
ch fo
llow
-up
exam
inat
ion
is p
erfo
rmed
. 3
Out
com
e of
cul
ture
repo
rted
as fo
llow
s:
No.
gro
wth
repo
rted
Neg
Fe
wer
than
10
colo
nies
E
xact
num
ber o
f col
onie
s 10
–10
0 co
loni
es
(+)
Mor
e th
an 1
00 c
olon
ies
(+ +
) In
num
erab
le o
r con
fluen
t gro
wth
(+
+ +
)
Tube
rcul
osis
Pro
gram
me
Form
III
41
Tube
rcul
osis
Tre
atm
ent C
ard
B
MU
TB
Reg
iste
r No.
___
____
__
Nam
e:
___
____
____
____
____
____
____
____
____
____
____
____
____
__
Sex
: M
F
D
ate
of re
gist
ratio
n: _
____
____
____
____
____
____
____
A
ge:
____
____
H
ealth
faci
lity:
___
____
____
____
____
____
____
____
__
Add
ress
: ___
____
____
____
____
____
____
____
____
____
____
____
____
____
_ N
ame
/ add
ress
of c
omm
unity
trea
tmen
t sup
porte
r (if
appl
icab
le)
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
Ref
erra
l by
:
Sel
f-ref
erra
l
Com
mun
ity m
embe
r
P
ublic
faci
lity
Priv
ate
faci
lity/
prov
ider
Oth
er, s
peci
fy__
____
__ I.
INIT
IAL
PHA
SE -
pre
scrib
ed re
gim
en a
nd d
osag
es
CA
T (I,
II ,
III):
Num
ber o
f tab
lets
per
dos
e an
d do
sage
of S
: (R
HZE
)
S
O
ther
Cot
rimox
azol
e
AR
V
Tick
app
ropr
iate
box
afte
r the
dru
gs h
ave
been
adm
inis
tere
d
Sput
um s
mea
r mic
rosc
opy
Dis
ease
site
(che
ck o
ne)
Pul
mon
ary
E
xtra
pulm
onar
y, s
peci
fy _
____
____
_ Ty
pe o
f pat
ient
(che
ck o
ne)
New
Tre
atm
ent a
fter d
efau
lt
Rel
apse
Tre
atm
ent a
fter f
ailu
re
Tra
nsfe
r in
O
ther
, spe
cify
___
____
____
____
____
Cul
ture
D
ST
Dat
e:
Dat
e re
sult
Res
ult
La
b
(R, S
, Nd,
(N
eg),(
Pos
),Nd,
cont
amin
ated
N
o.
Res
ult
cont
amin
ated
) M
onth
D
ate
Lab
No.
Res
ult
Wei
ght (
kg)
0
H
R
E
S
TB/H
IV
D
ate
Res
ult*
H
IV te
st
CP
T st
art
AR
T st
art
*) N
egat
ive; (
Ind
eter
mina
te; (
ND) N
ot D
unk
nown
(P
os) P
ositiv
e; (N
eg) I
one
/
Dai
ly s
uppl
y: e
nter
. P
erio
dic
supp
ly: e
nter
X o
n da
y w
hen
drug
s ar
e co
llect
ed a
nd d
raw
a h
oriz
onta
l lin
e (
) thr
ough
the
num
ber o
f day
s su
pplie
d. Ø
= d
rugs
not
take
n
D
ay
Mon
th
1
23
45
67
89
1011
1213
1415
1617
1819
2021
2223
2425
2627
2829
3031
Tube
rcul
osis
Pro
gram
me
Fo
rm II
I (co
ntin
ued)
42
Com
men
ts: _
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
___
____
____
____
____
____
____
____
____
____
____
____
____
___
____
____
____
____
____
____
____
____
____
____
____
____
___
____
____
____
____
____
____
____
____
____
____
____
____
___
II. C
ON
TIN
UA
TIO
N P
HA
SE
Num
ber o
f tab
lets
per
dos
e
(RH
)
(R
HE
)O
ther
Dai
ly s
uppl
y: e
nter
.
Per
iodi
c su
pply
, ent
er X
on
day
whe
n dr
ugs
are
colle
cted
and
dra
w a
hor
izon
tal l
ine
(
) th
roug
h th
e nu
mbe
r of d
ays
supp
lied.
Ø =
dru
gs n
ot ta
ken
D
ay
Mon
th
1
23
45
67
89
1011
1213
1415
1617
1819
2021
2223
2425
2627
2829
3031
X-ra
y (a
t sta
rt)
Dat
e:
Res
ults
(-),
(+),
ND
Trea
tmen
t out
com
e D
ate
of d
ecis
ion
____
C
ure
T
reat
men
t com
plet
ed
Die
d
T
reat
men
t fai
lure
D
efau
lt
T
rans
fer o
ut
HIV
car
e P
re A
RT
Reg
iste
r No.
CD
4 re
sult
A
RT
elig
ibili
ty (Y
/N/U
nkno
wn)
D
ate
elig
ibilit
y as
sess
ed
A
RT
Reg
iste
r No.
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
__
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
__
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
__
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
__
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
__
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
__
Nam
e an
d ad
dres
s of
con
tact
per
son:
___
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
___
Tube
rcul
osis
Pro
gram
me
Fo
rm IV
Tu
berc
ulos
is Id
entit
y C
ard
Nam
e:__
____
____
____
____
___
BM
U T
B R
egis
ter N
o. _
____
A
ddre
ss _
____
____
___
Dat
e tra
tion:
___
____
_ S
ex:
____
___
of re
gis
M
F
Age
:___
___
Dat
e tre
atm
ent s
tart
____
____
H
ealth
faci
lity:
___
____
____
____
____
____
____
____
____
____
Sup
porte
r (na
me
and
addr
___
____
____
____
____
____
____
ess)
Sput
um s
mea
r mic
rosc
opy
Mon
th
Dat
e La
b N
o.
Res
ult
Wei
ght
(kg)
0
D
isea
se s
ite (c
heck
one
) P
ulm
onar
y
E
xtra
pulm
onar
y, s
peci
fy _
____
Type
of p
(ch
at
ient
eck
one)
New
Tre
atm
ent a
fter d
efau
lt
Rel
apse
Tre
atm
ent a
fter f
ailu
re
Tra
nsfe
r in
Oth
er, s
peci
fy _
____
____
I. IN
ITIA
L PH
ASE
C
AT
(I, II
, III
):
(R
HZE
)S
O
ther
D
rugs
and
dos
age:
II. C
ON
TIN
UA
TIO
N P
HA
SE
(R
H)
(RH
E)
Oth
er
D
rugs
and
dos
age:
App
oint
men
t dat
es:
____
____
____
____
____
____
____
____
____
__
____
____
____
____
____
____
____
____
____
____
____
____
____
__
____
____
____
____
____
____
____
____
____
____
____
____
____
___
____
____
____
____
____
____
____
____
____
____
____
____
____
___
MB
E
_ E
RE
MR
Cul
ture
D
ST
Dat
e:
Dat
e re
sult
(Neg
),(+)
, Nd,
in
ated
La
Res
ult
b N
o.
Res
ult
ted)
co
ntam
(R, S
, Nd,
con
tam
ina
H
R
E
S
43
Tube
rcul
osis
Pro
gram
me
Form
V
TB R
egis
ter i
n B
asic
Man
agem
ent U
nit u
sing
Rou
tine
Cul
ture
and
DST
– L
eft s
ide
of th
e re
gist
er b
ook
Com
mun
ity s
uppo
rt 2
Type
of p
atie
nt 4
D
ate
of
regi
stra
tion
BM
U
TB N
o.
Nam
e
Sex M/F
Age
Add
ress
H
ealth
fa
cilit
y1
Date treatment
started
Treatment category
3
Site
P
/ EP
NR
FD
T
O
Ref
erra
l for
di
agno
sis
For
treat
men
t
Foot
note
s ap
pear
ing
on fi
rst p
age
of th
e re
gist
er o
nly
CA
T I:
N
ew c
ase
CA
T II:
R
e-tre
atm
ent
e.g.
2(R
HZE
)S/1
(RH
ZE)/5
(RH
E)
CA
T III
: N
ew s
putu
m s
mea
r mic
rosc
opy
nega
tive
PTB
and
EP
TB
e.
g. 2
(RH
ZE)/4
(RH
)
4 T
ick
only
one
col
umn
: N
=New
– A
pat
ient
who
has
nev
er h
ad tr
eatm
ent f
or T
B or
who
has
take
n an
titub
ercu
losi
s dr
ugs
for l
ess
than
1 m
onth
. R
=Rel
apse
– A
pat
ient
pre
viou
sly
treat
ed fo
r TB
, dec
lare
d cu
red
or
treat
men
t com
plet
ed, a
nd w
ho is
dia
gnos
ed w
ith b
acte
riolo
gica
l pos
itive
TB
(spu
tum
sm
ear m
icro
scop
y po
sitiv
e or
cul
ture
pos
itive
). F=
Trea
tmen
t afte
r fai
lure
– A
pat
ient
who
is s
tarte
d on
a re
-trea
tmen
t re
gim
en a
fter h
avin
g fa
iled
prev
ious
trea
tmen
t.
bact
erio
logi
cally
, fol
low
ing
inte
rrup
tion
of tr
eatm
ent f
or 2
or m
ore
cons
ecut
ive
mon
ths.
T=Tr
ansf
er in
– A
pat
ient
who
has
bee
n tra
nsfe
rred
from
ano
ther
TB
R
egis
ter t
o co
ntin
ue tr
eatm
ent.
This
gro
up is
exc
lude
d fro
m th
e Q
uarte
rly
Rep
orts
on
TB C
ase
Reg
istra
tion
and
on T
reat
men
t Out
com
e.
O=O
ther
pre
viou
sly
trea
ted
– A
ll ca
ses
that
do
not f
it th
e ab
ove
defin
ition
s.
This
gro
up in
clud
es s
putu
m s
mea
r mic
rosc
opy
posi
tive
case
s w
ith
unkn
own
hist
ory
or u
nkno
wn
outc
ome
of p
revi
ous
treat
men
t, pr
evio
usly
tre
ated
spu
tum
sm
ear m
icro
scop
y ne
gativ
e ca
ses,
pre
viou
sly
treat
ed E
P
and
chro
nic
case
(i.e
. a p
atie
nt w
ho is
spu
tum
sm
ear m
icro
scop
y po
sitiv
e at
the
end
of a
re-tr
eatm
ent r
egim
en).
1 F
acili
ty w
here
pat
ient
’s tr
eatm
ent c
ard
is k
ept.
In c
ase
seve
ral c
opie
s ar
e ke
pt, t
he m
ost p
erip
hera
l fac
ility
shou
ld b
e en
tere
d. U
se s
tand
ardi
zed
type
of h
ealth
fa
cilit
ies
acco
rdin
g to
blo
ck 2
of t
he Y
early
Rep
ort o
n P
rogr
amm
e M
anag
emen
t in
BM
U. H
ealth
faci
lity
is d
efin
ed a
s an
y he
alth
inst
itutio
n w
ith h
ealth
car
e pr
ovid
ers
form
ally
eng
aged
in a
ny o
f the
follo
win
g TB
con
trol f
unct
ions
(DO
TS):
refe
rring
TB
sus
pect
s/ca
ses,
labo
rato
ry d
iagn
osis
, TB
trea
tmen
t and
pat
ient
sup
port
durin
g tre
atm
ent.
2 C
omm
unity
sup
port
is p
rovi
ded
by tr
aine
d an
d su
perv
ised
info
rmal
pra
ctiti
oner
s, c
omm
unity
wor
ker/v
olun
teer
, fam
ily m
embe
rs, f
riend
s pr
ovid
ing
serv
ices
out
side
a
faci
lity
(hea
lth in
stitu
tion)
. 3
Ent
er th
e tr
eatm
ent c
ateg
ory:
D=T
reat
men
t afte
r def
ault
– A
pat
ient
who
retu
rns
to tr
eatm
ent,
posi
tive
44
Tube
rcul
osis
Pro
gram
me
Form
V (c
ontin
ued)
45
T
B R
egis
ter i
n B
asic
Man
agem
ent U
nit u
sing
Rou
tine
Cul
ture
and
DST
– R
ight
sid
e of
the
regi
ster
boo
kR
esul
ts o
f spu
tum
sm
ear m
icro
scop
y an
d ot
her e
xam
inat
ions
Tr
eatm
ent o
utco
me
& d
ate
TB/H
IV a
ctiv
ities
B
efor
e tre
atm
ent
2 or
3 m
onth
s 1
5 m
onth
s E
nd o
f tre
atm
ent
Spu
tum
sme
mi
date
/No.
/ R
esul
t2
ult
/ da
te
C
ultu
date
/No.
/ R
esul
t 5S
T da
te/N
o./
Res
ult 6
Spu
tum
sm
ear
mic
ros-
Res
ult2
Cul
ture
N
o./
Res
ult5
Spu
tum
copy
N
o./
Res
ult2
Cul
ture
N
o./
Res
ult5
um ar
copy
N
o./
Res
ult2
Cul
ture
N
o./
Dat
e O
ut7
date
Y/N
S
tart
a
Rem
arks
ar
cros
- co
py
HIV
res
Dat
e
3 /X-
ray
Res
ult4
re
D
c Nopy
o.
/
smea
r m
icro
s-
Spu
tsm
em
icro
s-
Res
ult5
com
e in
text
A
RT
Y/N
S
tart
CP
T
dte
Foot
note
s ap
pear
ing
on fi
rst p
age
of th
e re
gist
er o
nly
1 C
AT
I pat
ient
s ha
ve fo
llow
-up
sput
um s
mea
r mic
rosc
opy
exam
inat
ion
at 2
mon
ths;
CA
T II
patie
nts
have
follo
w-u
p sp
utum
sm
ear m
icro
scop
y ex
amin
atio
n at
3
2 (N
t su
gest
ive
of T
B; (
ND
): N
ot D
one.
amp
zid;
(Res
istE
): R
esis
tais
tRH
): R
(
per
pat
ient
: ni
ng o
f st
m T
does
not
mee
t tTrm
onth
s. C
AT
I pat
ient
s w
ith in
itial
pha
se o
f tre
atm
ent e
xten
ded
to 3
mon
ths
have
follo
w-u
p sp
utum
sm
ear m
icro
scop
y ex
amin
atio
ns a
t 2 A
ND
3 m
onth
s w
ith
resu
lts re
gist
ered
in th
e sa
me
box.
D
): N
ot d
one;
(NEG
): 0
AFB
/100
fiel
ds; (
1-9)
: Exa
ct n
umbe
r if 1
to 9
AFB
/100
fiel
ds; (
+): 1
0-99
AFB
/100
fiel
ds; (
++):
1-10
AFB
/ fie
ld; (
+++)
: > 1
0 A
FB/ f
ield
3
(Pos
):Pos
itive
; (N
eg):N
egat
ive;
(I):I
ndet
erm
inat
e; (N
D):N
ot D
one
/ unk
now
n. D
ocum
ente
d ev
iden
ce o
f HIV
test
per
form
ed d
urin
g or
bef
ore
TB tr
eatm
ent i
s re
porte
d he
re. M
easu
res
to im
prov
e co
nfid
entia
lity
shou
ld a
ccom
pany
reco
rdin
g of
HIV
sta
tus.
4
(Pos
): S
ugge
stiv
e of
TB
; (N
eg):
No
g:
5 (P
os):
Pos
itive
; (N
eg)
Neg
ativ
e; (N
D):
Not
Don
e.
6 (R
esis
tR):
Res
ista
nt to
Rif
icin
; (R
esis
tH):
Res
ista
nt to
Ison
iant
to E
tham
buto
l; (R
esis
tStre
pt):
Res
ista
nt to
Stre
ptom
ycin
; (R
eses
ista
nt to
Rifa
mpi
cin
and
Ison
iazi
d;
Sus
cept
): S
usce
ptib
le; (
ND
): N
ot D
one.
ol
low
ing
outc
omes
7 W
rite
clea
rly O
NE
of th
e f
Cur
e: P
atie
nt w
ith c
ultu
re o
r spu
tum
sm
ear m
icro
scop
y po
sitiv
e at
the
begi
non
th o
f tre
atm
ent a
nd o
n at
leas
t one
pre
viou
s oc
casi
on.
the
treat
men
t who
was
cul
ture
or s
putu
m s
mea
r mic
rosc
opy
nega
tive
in th
e la
he c
riter
ia to
be
clas
sifie
d as
a c
ure
or a
failu
re.
reat
men
t com
plet
ed: P
atie
nt w
ho h
as c
ompl
eted
trea
tmen
t but
who
ea
tmen
t fai
lure
: New
pat
ient
who
is c
ultu
re o
r spu
tum
sm
ear m
icro
scop
y p
men
t bec
ause
spu
tum
sm
ear m
icro
scop
y tu
rned
out
to b
e M
DR
TB. P
revi
ousl
ositi
ve a
ttre
aty-
trea
of
htu
m tu
rned
o
Def
ase
cutiv
e m
onth
s or
mor
e.
Tran
sfer
out
: Pat
ient
who
has
bee
n tra
nsfe
rred
to a
hea
lth fa
cilit
y in
ano
ther
BM
U a
nd fo
r who
m tr
eatm
ent o
utco
me
is n
ot k
now
n.
5 m
onth
s or
late
r dur
ing
treat
men
t, or
who
is s
witc
hed
to C
ateg
ory
IV
ted
patie
nt w
ho is
cul
ture
or s
putu
m s
mea
r mic
rosc
opy
posi
tive
at th
e en
d ut
to b
e M
DR
TB.
is re
-trea
tmen
t or w
ho is
sw
itche
d to
Cat
egor
y IV
trea
tmen
t bec
ause
spu
Die
d: P
atie
nt w
ho d
ies
from
any
cau
se d
urin
g th
e co
urse
of t
reat
men
t. ul
t: P
atie
nt w
hose
trea
tmen
t was
inte
rrup
ted
for 2
con
Tube
rcul
osis
Pro
gram
me
Fo
rm V
I Q
uart
erly
Rep
ort o
n TB
Cas
e R
egis
trat
ion
in B
asic
Man
agem
ent U
nit u
sing
Rou
tine
Cul
ture
re
1
__
ordi
nato
r:___
___
____
__
atur
e: _
___
____
__
____
__ q
uart
er o
f yea
r___
___
Dat
e of
co
s f
____
__
____
____
____
____
__
Fac
ility
___
____
___
____
____
____
___
____
__
Sig
n__
____
Pat
ient
s re
gist
e d
durin
g
mpl
etio
n of
thi
orm
: __
____
_
te
ry s
putu
m s
mea
r mic
rosc
opy
poN
ew p
ulm
sput
um s
me
egat
ive
pul
ry s
putu
m
smea
r mic
rosc
opy
not
done
/ no
t av
New
Ext
rapu
lmon
ary
case
s re
gis
red
2
sitiv
e on
ary
mic
rosc
opy
nar
New
mon
a
aila
ble
ses
Prev
ious
ly tr
eate
d
rs
>15
yrs
R
elap
se
Afte
r fa
ilure
Af
ter
defa
ult
0-4
yrs
5-14
yr
s
>1
5
yrs
Cu
(-)
Cu
(+)
Cu (-)
Cu
(+)3
Cu (-)
Cu
(+)3
Cu (-)
Cu
(+)3
Cu (-)
Cu
(+)
Cu (-)
Cu
(+)
Cu (-)
Cu
(+)
Cu (-
0-4
yrs
5-14
yr
s
)
>15
yrs
0-4 rs
5-14
yr
s >
y15
s
Oth
er
pvi
ousl
treat
ed 4
TOTA
L a
ll ca
ses
yr
rey
lmon
ary
sput
um s
me
mic
roop
y po
sitiv
e ca
se -
Ag
0-4
5-14
15
-24
25-3
4
4 55
-6
arsc
s 35-4
e gr
oup
45
-54
4>
65
Tota
l
: 1 J
uly–
30 S
epte
mbe
r;
ted
sput
um s
mea
r mic
rosc
opy
nega
tive
and
cultu
re n
egat
ive
the
quar
ter,
with
out i
nclu
ding
pat
ient
s w
ith e
xam
inat
ion
beca
use
of fo
llow
-up.
tory
act
ivity
- sp
utum
sm
ear m
icro
scop
y an
d cu
lture
5
B
lock
4: T
B/H
IV a
ctiv
ities
is b
ased
on
date
of r
egis
tratio
n of
cas
es in
the
TB R
egis
ter,
follo
win
g th
e de
cisi
on to
sta
rt tre
atm
ent.
Q1:
1 J
anua
ry–3
1 M
arch
; Q2:
1 A
pril
–30
June
; Q3
ecem
ber.
chr
onic
cas
es a
re e
xclu
ded.
as
es w
ith s
putu
m s
mea
r mic
rosc
opy
nega
tive
and
cultu
re p
ositi
ve a
re in
clud
ed in
this
box
. at
ed c
ases
incl
ude
pulm
onar
y ca
ses
with
unk
now
n hi
stor
y, u
nkno
wn
resu
lt of
pre
viou
s tre
atm
ent,
prev
ious
ly tr
eaic
cas
es a
re e
xclu
ded.
nd
pre
viou
sly
treat
ed e
xtra
pulm
onar
y ca
ses.
‘Tra
nsfe
rred
in’ a
nd c
hron
the
TB L
abor
ator
y R
egis
ter b
ased
on
“Dat
e sp
ecim
en re
ceiv
ed” i
n th
e la
bora
tory
dur
ing
ce o
f HIV
test
s (a
nd re
sults
) per
form
ed in
any
reco
gniz
ed fa
cilit
y be
fore
TB
dia
gnos
is o
r dur
ing
TB tr
eatm
ent (
till e
nd o
f the
qua
rter)
sho
uld
be re
porte
d he
re.
TB tr
eatm
ent 6
s H
IV
posi
tive
6
cts
exam
ined
for
tum
sm
ear
Out
of (
a), N
o. w
ith p
ositi
ve s
putu
m
smea
r mic
rosc
opy
No.
pat
ient
s te
sted
for
HIV
bef
ore
or d
urin
g N
o. p
atie
nt
m
icro
scop
y po
sitiv
e TB
New
spu
tum
sm
ear
cts
exam
ined
for
tum
cul
ture
(b)
Out
of (
b), N
o. w
ith p
ositi
ve c
ultu
re
Al
l TB
case
s
46
__
Name
of B
MU
Co
Nam
e of
TB
Blo
ck 1
: Pulm
ona
All
TB
New
ca
0-4
yrs
5-14
y
Cu
Cu
C
u (+
) (-)
(+
)
oc
k 2.
Nw
pu
Sex
B
le
M
F 1
2 ’
3
4
5
6 Blo
ck 3
: Lab
ora
Reg
istra
tion
perio
dQ
4:1
Oct
ober
–31
DTr
ansf
erre
d in
’ and
Pre
viou
sly
treat
ed c
Oth
er p
revi
ousl
y tre
pulm
onar
y ca
ses
aD
ata
colle
cted
from
Doc
umen
ted
evid
en
No.
of T
B s
uspe
diag
nosi
s by
spu
mic
rosc
opy
(a)
No.
of T
B s
uspe
diag
nosi
s by
spu
Tube
rcul
osis
Pro
gram
me
Form
VII
47
Qur
e
____
____
___
____
___
g1
_
uart
erly
Rep
ort o
n TB
Tre
atm
ent O
utco
mes
and
TB
/HIV
Act
iviti
es in
BM
U u
sing
Rou
tine
Cul
t
Nam
e of
BM
U:
____
____
____
____
____
_
Faci
lity:
____
____
____
____
____
____
__ N
ame
of T
B C
oord
inat
or:_
____
____
____
____
____
_
S
igna
ture
: __
____
____
___
____
__
D
ate
of c
ompl
etio
n of
this
form
: __
____
____
____
Pat
ient
s re
gist
ered
dur
in
____
__ q
uart
er o
f yea
r___
Blo
ck 1
: TB
trea
tmen
t out
com
es
Trea
tmen
t out
com
es
Type
ta
l num
ber o
f pa
tient
s urin
g
)
com
ple
( 2 )
failu
re 2
( 4
Def
ault
5 )
Tran
sfer
out
( 6 )
Tota
l num
ber
eval
uate
d fo
r ut
com
of
of c
ase
To regi
ster
ed d
quar
ter *
Cur
e Tr
eatm
ent
( 1
ted
)
Die
d Tr
eatm
ent
( 3
) (
o(s
um
es:
to 6
) 1
New
spu
t
and/
or c
uliv
um
sm
ear
ture
pos
itm
icro
scop
ye
posi
tive
Ne
negw
ms
a
on
spu
tum
sr u
nkea
r mno
wic
ro
copy
and
cultu
re
tiv
e
New
extra
ulm
onar
y
p
Rel
apse
s sp
utum
sm
ear m
icro
scop
y po
sitiv
e an
d/or
cul
ture
pos
itive
Tea
tmen
t afte
utum
y po
d/or
cu
itive
rr f
ailu
re s
p s
mea
r m
icro
scop
sitiv
e an
lture
pos
Trea
tmen
t afte
r def
ault
sput
um s
mea
r m
icro
scop
y po
sitiv
e an
d/or
cul
ture
pos
itive
Oth
er p
revi
ousl
y tre
ated
3
* Th
ese
num
bers
are
tran
sfer
re__
____
____
____
____
____
d fro
tratio
n fo
r the
abo
ve q
uarte
r. S
peci
f__
___
____
____
____
___
____
____
____
____
____
____
____
____
____
____
____
___
____
Blo
ck 2
: TB
/HIV
act
iviti
es (s
ame
quar
ter a
naly
sed
as B
lock
1)
n C
Pm th
e Q
uarte
rly R
epor
t on
TB C
ase
Reg
is__
____
____
____
_y
any
excl
usio
n: _
____
____
____
____
___
____
____
____
__
____
_
N
o. p
atie
nts
oT
4N
o. p
atie
nts
on A
RT
5
All
TB c
ases
1
Qua
rter:
This
form
app
lies
to p
atie
nts
regi
ster
ed (r
ecor
ded
in th
e B
MU
TB
Reg
iste
r) in
the
quar
ter t
hat e
nded
12
mon
ths
ago.
For
exa
mpl
e, if
com
plet
ing
this
form
at t
he
resu
lt of
pre
viou
s tre
atm
ent,
prev
ious
ly tr
eate
d sp
utum
sm
ear m
icro
scop
y an
d cu
lture
neg
ativ
e pu
lmon
ary
case
s, a
nd p
revi
ousl
y
begi
nnin
g of
the
3rd
quar
ter,
reco
rd d
ata
on p
atie
nts
regi
ster
ed in
the
2nd
quar
ter o
f the
pre
viou
s ye
ar.
ed to
Cat
IV b
ecau
se s
putu
m s
ampl
e ta
ken
at s
tart
of tr
eatm
ent t
urne
d ou
t to
show
MD
RTB
. 2
Incl
ude
patie
nts
switc
h3
Incl
udes
pul
mon
ary
case
s w
ith u
nkno
wn
treat
ed e
xtra
pulm
onar
y ca
ses.
4
Incl
udes
TB
pat
ient
s co
ntin
uing
on
CP
T st
arte
d be
fore
TB
dia
gnos
is o
r tho
se s
tarte
d du
ring
TB tr
eatm
ent (
till l
ast d
ay o
f TB
trea
tmen
t).
5 In
clud
es T
B p
atie
nts
cont
inui
ng o
n A
RT
star
ted
befo
re T
B d
iagn
osis
AN
D th
ose
star
ted
durin
g TB
tre
atm
ent (
till l
ast d
ay o
f TB
trea
tmen
t).
Tuberculosis Programme Form VIII
Quarterly y Supplies
in Basic Management Unit Labo ry su rs are prepared every 3 months with ne con
_ _ Facility: ________________
nd si
_ quarter of year___
Order Form for Culture and DST Laborator
pply orderato
U: ____
gna
eds based on
____
sumption1
___ Name of BM Name a
______
Laboratory item
Culture2
Culture media vTriple packa gginPipette/Loops Media preparedL-Jensen powdeTube/vial with cPipette /Loops DST with liquVials with lyophmedia Pipette or syringAntibiotic powdeAntibiotic powdeAntibiotic powdeAntibiotic powde DST with soliL-Jensen powdeTube/vial with cPipette/Loops Antibiotic powdeAntibiotic powdeAntibiotic powdeAntibiotic powde DST with soliCulture mediumCulture mediumCulture mediumCulture mediumPipette/Loops
1 Based o2 Adapt
n the to co
lasuntry
_
_____________________ Date of completion of this form: _________
48
ture: ___________
unit
(a) Average quarterly
consumption1
Re buff k
(b) =
(c) Stock in unit
last day previouquarte
(d) s
(d) = )
s Measurement
(b) quer st
iredoc
(a) s r
No.to orde
(a)+
of
(b)-
unitr (c
ials (tubes) sys tem
on site2 r
aps
id media2
ilized TB
e r R r H r S r E
d me red on site2dia prepar
aps
r R r H r S r E
d media received from NRL2
vials with R vials with H
S vials with E vials with
y sumptiosettin d logistic optiot ear’s con n
n.
g an
49
Revised TB Recording and Reporting forms and registers
4. Part III: Additional TB dat in Basic Management Unit
ised TB Recording and Reporting forms and registers
4. Part III: Additional TB dat in Basic Management Unit
aa
Ad data are circled in blue in each form: Re oved data circled in red da ed line in the rrent set of forms (annexes, pages 56-71)
RaAd ented in this part III. These forms are the Register fo gister fo e rt on Sputum Smear Microscopy Co ter of Referred TB Cases. Ad itional data which are op the essential forms presented in El ting, especia if it is based on individual registration, will modify th electronic quarterly reports need to remain minimal at ev
ditional or modified
m sh cu .
tionale ditional forms which are optional are pres
r TB Suspects, Re r TB Contacts, Quarterly R ponversion and, Regis
d tional are listed and can be added to parts I and II.
ectronic recording and repor llye scope of reported data. However, ery level of care for better use of generated data.
Tube
rcul
osis
Pro
gram
me
Fo
rm A
50
is
Ts
TB
Nam
e of
TB
Su
spec
t
Age
M
F
s ate
tum
cte
d
Date
sputu
m se
nt to
labor
atory
Reg
Com
plet
e A
ddre
s
ter o
fB
Sus
p
Res
ult
of
HIV
te
st *
D spu
colleec
t
Dat
e Su
spec
t Nu
mber
D res
recat u ei
Res
ults
of
Spu
tum
E
xam
inat
ions
1
2
3
TB
Trea
tmen
t C
ard
ened
co
rd
ate)
Obs
erva
tions
/ C
linic
ian’
s D
iagn
osis
e lts
ved
Op (re d
__
____
____
___
___
Yea
r ___
____
____
____
____
____
___
__
__
____
____
___
___
__
____
____
___
__
____
____
___
___
__
____
____
___
__
____
____
___
___
__
____
____
__
__
____
____
___
___
__
____
____
___
__
____
____
____
____
_
__
____
____
__
____
____
____
____
_
__
____
____
__
____
____
____
____
_
__
____
____
__
____
____
____
____
_
__
____
____
__
____
____
____
____
_
__
____
____
__
____
____
____
____
_
__
____
____
__
____
____
____
____
_
__
____
____
* (P
os) P
ositi
ve; (
Neg
) Neg
ativ
e; (I
) Ind
eter
min
ate;
(ND
) Not
Don
e / u
nkoc
umd
evid
ce o
f HIV
test
per
form
ed d
urin
g or
bef
ore
TB tr
eatm
ent i
s re
porte
d he
re.
now
n. D
ente
en
Tube
rcul
osis
Pro
gram
me
51
Bel
ow a
re p
ossi
ble
addi
tions
to fo
rms
pres
ente
d in
par
t I o
r II
Form
B: T
B L
abor
ator
y R
egis
ter
O
ne a
dditi
onal
col
umn:
"HIV
resu
lt" m
ay b
e ad
ded
afte
r the
col
umn
"Res
ults
of s
putu
m s
mea
r mic
rosc
opy
exam
inat
ion"
. Fo
rm C
: Tub
ercu
losi
s Tr
eatm
ent C
arFr
ont o
f ca
d:n
n da
ily a
nti-T
B d
rug
adm
inis
tratio
n d
nse
nte
r ad
mre
serr
ent v
ersi
o a
nnex
se
2. T
otal
No.
dos
n,en
to s
date
, s
give
n to
su
rter -
do
Bac
k of
car
d: tw
o ad
ditio
nal c
olum
ns: B
ox o
n da
ily a
nti-T
B d
rug
adm
inis
tratio
n du
ring
cont
inua
tise
may
be
co
lum
ns (a
s pr
esen
ted
in th
e cu
rren
ter
on,
nnex
4 -
back
): 1.
No.
dos
es th
is m
onth
, 2. T
otal
no.
dos
es g
iven
. Fo
rm D
: Bas
ic M
anag
emen
t Uni
t TB
Reg
iste
r (as
sho
wn
in th
e TB
Reg
iste
r in
BM
U u
sing
Rou
tine
Cul
ture
and
DS
T, fo
rm V
, pa
ge 4
5)
Left
side
of t
he re
gist
er b
ook
Two
addi
tiona
l col
umns
on
"Com
mun
ity s
uppo
Com
mun
ity s
uppo
rt fo
r tre
atm
ent"
may
be
adde
d af
ter t
he c
olum
n "H
ealt
faci
lity.
" The
se tw
o co
lum
ns
ll su
mm
ariz
e th
e co
mm
unity
con
tribu
tion
to T
B c
ontro
l and
will
faci
litat
e th
e re
po in
Y
earl
Rep
ort o
n P
rogr
amm
e M
anag
emen
t, fo
rm 1
0.
Add
foot
note
: Com
mun
ity s
uppo
rt is
pro
vide
d by
trai
ned
and
supe
rvis
ed in
fopr
actit
ione
rs, c
omm
unity
wor
kers
/vol
unt
rfri
ends
pro
vidi
ng s
ervi
ces
outs
ide
a fa
f t
he re
gist
er b
ook,
Fi
rst c
olum
n "
IV re
sult,
dat
e" m
ay b
ecom
e "H
gist
er n
umbe
r"
"AR
T, Y
/N, s
tart
date
" may
bec
ome
" AR
T, Y
/, s
tart
date
, AR
T R
egis
ter n
umbe
r"
Form
E: Q
uart
erly
Rep
ort o
n TB
Cas
e R
egis
trat
ion
in B
asic
Man
agem
ent
Uni
t re
e ag
e br
eakd
owns
(0ar
s; 5
–14
year
s; >
d s:
Bx
or
ns (a
s p
4. D
rug fo
ur a
dditi
onal
col
umnt
ed in
the
cupp
o
our
ig
initi
al p
hase
may
b
on p
ha
e pr
ees
giv
ed
with
fou
3. D
rugs
giv
ditio
nal
uppo
rter -
two
addi
tiona
l
colu
n,se
s.
4 - f
ront
): 1.
No.
do
s th
is m
onth
,
pre
sent
ed w
ith v
sia rt,
refe
rral
for d
iagn
osis
" and
"h
wi
rtbl
ock
3 of
the
y
rmal
ee
rs, f
amily
mem
bes,
ci
lity
(hea
lth in
stitu
tion)
.
Rig
ht s
ide
oH
IV re
sult,
dat
e, P
re-A
RT
Re
N
Blo
ck 1
: Th
–4 y
e15
yea
rs) i
nste
ad o
two
(0–1
4 ye
ars;
f
>15
year
s) m
ay b
e us
ed in
the
colu
mns
"New
pu
lmon
ary
sput
um s
mea
r mic
rosc
opy
nega
tive"
r mic
rosc
opy
not d
one/
not a
vaila
ble"
, New
ext
rapu
lmon
ary"
B
lock
2: A
ge b
reak
dow
n 0–
14 m
ay b
e di
vide
d in
to tw
o ag
e br
eakd
owns
(0–4
yea
rs a
nd–1
4 ye
ars)
. B
lock
3: T
wo
colu
mns
may
be
adde
d: "O
ut o
f col
umn
ed fo
r HIV
", "O
ut o
f col
umn
2, n
umbe
r with
HIV
pos
it
, "P
ulm
onar
y sp
utum
sm
ea 5
1, n
umbe
r tes
tiv
e te
st"
Tube
rcul
osis
Pro
gram
me
Fo
rm F
ame
Inde
x ca
se
Age
Se
x R
egis
ter
Nam
e of
con
tact
1A
ddre
ss o
f con
tact
sc
reen
ing
2R
esul
t of s
cree
ning
2R
emar
ks
52
Reg
iste
r of T
B C
onta
cts
NB
MU
TB
Met
hod
of
No
1 L
ist a
ll co
ntac
ts c
onse
cutiv
ely
unde
r the
nam
e of
the
inde
x ca
se. (
Def
initi
on o
f con
tact
is to
be
incl
uded
.) 2
Lis
t and
cod
e ar
e to
be
defin
ed.
Yea
r
____
____
____
___
Faci
lity
____
____
____
____
____
____
____
Tuberculosis Programme Form G
Quarterly Report on Sputum Smear Microscopy Conversion
Name of BM _____________ Facility: __________
Name and signa
_____ quarter of year______
U: ____
Numbesputum smeapositive case
quarte cor re
1 Quarter:
months agre
T
gistered e
is number show of the Quarte
2 Thro
his foro. For in th
_
53
ture: ______________________________ Date of completion of this form: ______
Sputum smear microscopy conversion at:
r of new r microscopy
s registered in rded above2
Sputum smear microscopy not done at either 2 or 3
months 2 months 3 months
Total converted at 2 or 3 months:
es to patients registered (recorded in the BMU TB Register) in the quarter that ended 3 le, if completing this form at the beginning of the 3rd quarter, record data on patients
1st quarter.
uld match the number of new sputum smear microscopy positive cases in Block 1, Column 1, first rly Report on TB Case Registration previously completed for patients registered in this quarter.
m appli examp
Tube
rcul
osis
Pro
gram
me
Fo
rm H
54
Qua
rter
ly R
epor
t on
TB T
reat
men
t Out
com
es a
nd T
B/H
IV a
ctiv
ities
in B
MU
Nam
e of
BM
U:
____
____
____
____
____
F
acili
ty:_
____
____
____
____
____
____
____
____
___
Nam
e of
TB
Coo
rdin
ator
:___
____
____
____
____
_
S
igna
ture
: __
____
____
____
____
____
__
Patie
nts
regi
ster
ed d
urin
____
er o
f yea
r___
Dat
e of
of t
his
form
____
___
g1
__ q
uart
com
plet
___
: __
ion
____
Blo
ck 1
: TB
trea
tmen
t out
com
es
Trea
tmen
t out
com
es
Type
of c
ase
Tota
l num
ber o
f pa
tient
s re
gist
ered
dur
ing
quar
ter *
Cur
e ( 1
)
Trea
tmen
t co
mpl
eted
( 2
)
Die
d (
Trea
tmen
t fa
ilure
2
( 4 )
DTr
ansf
er o
ut
( 6
)
num
uate
dco
m(
of 1
3
)
efau
lt
( 5 )
Tota
lev
al out
sum
ber
for
es:
to 6
)
New
spu
tum
sm
ear m
icro
scop
y po
sitiv
e N
ew s
putu
m s
mea
r mic
rosc
opy
nega
tive
New
spu
tum
sm
ear m
icro
scop
y no
t don
e
N
ew e
xtra
pulm
onar
y
R
elap
se
Trea
tmen
t afte
r fai
lure
Tr
eatm
ent a
fter d
efau
lt
O
ther
pre
viou
sly
treat
ed 3
* The
se n
umbe
rs a
re tr
ansf
erre
d fro
m th
e Q
uarte
rly R
epor
t on
TB C
ase
Reg
istra
tion
for t
he a
e qu
arte
r. S
peci
fy a
ny e
xclu
____
__
___
____
____
____
____
____
___
____
____
___
____
_ B
lock
2: T
B tr
eatm
ent o
utco
mes
of H
IV-p
ositi
ve p
atie
nts
Tr
em
ent o
utco
mes
bov
___ at
sion
. __
____
___
___
___
___
___
___
____
___
_ __
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
Type
of c
ase
Tota
l num
ber o
f H
IV-p
ositi
ve T
B
patie
nts
Blo
ck 3
, C
olum
n (a
)*
Cur
e ( 1
)
Trea
tmen
t co
mpl
eted
( 2
)
Die
d ( 3
)
Trea
tmen
t fa
ilure
2 ( 4
)
Def
ault
( 5
)
Tran
sfer
out
( 6 )
num
eval
uate
dou
tcom
(sum
of 1
Tota
lbe
r fo
r es
: to
6)
All
TB c
ases
New
spu
tum
sm
ear m
icro
scop
y po
s. T
B
* O
f the
se T
B/H
IV p
atie
nts,
___
____
(num
ber)
, spe
cify
any
exc
lusi
on: _
____
____
____
____
____
____
____
____
____
____
___
____
___
___
Blo
ck 3
nt
s on
N
o. p
R
____
___
CP
T
__
___
atie
____ o
___
T : T
B/H
IV a
ctiv
ities
(sam
e qu
arte
r ana
lyse
d as
Blo
ck 1
)N
o. p
atie
nts
test
ed fo
r HIV
4N
o. p
atie
nts
HIV
-pos
itive
(a) 4
No.
pat
ie5
nts
n A
6
All
TB c
ases
N
ew s
putu
m s
mea
r mic
rosc
opy
posi
tive
TB
1 Q
uarte
r: Th
is fo
rm a
pplie
s to
pat
ient
s re
gist
ered
(rec
orde
d in
the
BM
U T
B R
egis
ter)
in th
e qu
arte
r tha
t end
ed 1
2 m
onth
s ag
o. F
or e
xam
ple,
if c
or t
hen
reco
rd d
ata
on p
atie
nts
regi
ster
ed in
the
2nd
quar
ter o
f the
pre
viou
s ye
ar.
2 In
clud
e pa
tient
s sw
itche
d to
Cat
IV b
ecau
se s
putu
m s
ampl
e ta
ken
at s
tart
of tr
eatm
ent t
urne
d ou
t to
be M
DR
TB.
3 In
clud
e pu
lmon
ary
case
s w
ith u
nkno
wn
resu
lt of
pre
viou
s tre
atm
ent,
prev
ious
ly tr
eate
d sp
utum
sm
ear m
icro
scop
y ne
gativ
e pu
lmon
ary
case
s, o
r pre
vio
reat
ed s
putu
m s
mea
r n
ot d
one
pulm
onar
y ca
ses
and
prev
ious
ly tr
eate
d ex
trapu
lmon
ary
case
s.
4 D
ocum
ente
d ev
iden
ce o
f HIV
test
s (a
nd re
sults
) per
form
ed in
any
reco
gniz
ed fa
cilit
y be
fore
TB
dia
gnos
is
mpl
etin
g th
is fo
rm a
t th
usly
t
e cl
ose
of th
e se
cond
qua
rte
mic
rosc
opy
or d
urin
g TB
trea
tmen
t (til
l las
t day
of T
B tr
eatm
ent)
shou
ld b
e re
porte
d h
5 In
clud
es T
B p
atie
nts
cont
inui
ng o
n C
PT
star
ted
befo
re T
B d
iagn
osis
er
e.
or th
ose
star
ted
durin
g TB
trea
tmen
t (til
l las
t day
of T
B tr
eatm
ent).
6
Incl
udes
TB
pat
ient
s co
ntin
uing
on
AR
T st
arte
d be
fore
TB
dia
gnos
is A
ND
thos
e st
arte
d du
ring
TB t
reat
men
t (til
l las
t day
of T
B tr
eatm
ent).
Tube
rcul
osis
Pro
gram
me
Fo
rm I
55
R
egis
ter o
f Ref
erre
d TB
Cas
es
Ser
ial
No.
D
ate
Nam
e A
ge
Sex
Dis
ease
si
te
(P/E
P)
Sen
ding
U
nit/S
ervi
ce
Dat
e
Trea
tmen
t st
arte
d (if
sta
rted)
Ref
erre
d to
(fa
cilit
y/B
MU
) D
ate
of
arriv
al
Rem
arks
Yea
r ___
____
____
____
Fa
cilit
y __
____
____
____
____
____
____
__
Form
to b
e us
ed o
nly
in fa
cilit
ies
refe
rring
a la
rge
num
ber o
f TB
sus
pect
s.
56
WHO recommended TB recording and reporting forms and registers
5. Annexes: Current TB forms and registers
removed data are circled in a red dashed line in each form.
Source: Management of tuberculosis: training for district TB coordinators, (WHO/HTM/TB/2005.347a-m) and Management of tuberculosis: training for health facility staff, (WHO/CDS/TB/2003.314a-k)
Annex 1
TB LABORATORY FORM
REQUEST FOR SPUTUM EXAMINATION
Name of health facility ____________________________ Date _________________
Name of patient ________________________________ Age ______ Sex: M F
Complete address __________________________________________________________
_______________________________ District _______________
Reason for examination: Diagnosis π TB Suspect No. ______________
OR Follow-up π Patient’s District TB No..* ______________
Disease site: Pulmonary Extrapulmonary (specify) _______
Number of sputum sample nt with this form _____
Date of collection of first sa _______ Signature of spe imen collector ________
* Be sure to enter the patient’s District TB No. for follow-up of patients on TB treatment.
RESULTS (to be completed by Laboratory)
Lab. Serial No. ____________________
(a) Visual appearance of sputum:
Mucopurulent Blood-stained Saliva
(b) Microscopy:
DATE SPECIM
_______
s se
mple ____
________
c
1
2
3
Date _______ E
The completed form (withTuberculosis Unit.
EN RESULTS
+++
xamined by (Signature) ______
results) should be sent to the he
POSITIVE (GRADING) ++ + sca
_____________________
alth facility and to the Dis
57
nty (1–9)
_______
trict
58
Anne
x 2
REG
ISTE
R O
F TB
SU
SPEC
TS
Date
TB S
uspe
ct Nu
mber
Na
me of
TB
Susp
ect
Age
M
F Co
mplet
e Add
ress
Da
te Sp
utum
Sent
to La
b Da
te Re
sults
Re
ceive
d
Resu
lts of
Sp
utum
Exam
inatio
ns
1
2
3
TB
Trea
tmen
t Ca
rd
Open
ed?
(reco
rd da
te)
Obse
rvatio
ns/
Clini
cian’s
Diag
nosis
Yea
r ___
____
____
____
Fa
cilit
y __
____
____
____
____
____
59
An
nex
3
GIS
TER
R
easo
n fo
r ex
amin
atio
n*
Mic
rosc
opy
resu
lts
TB L
AB
OR
ATO
RY
RE
Lab
Ser
ial
No.
D
ate
Nam
e (in
full)
Se
x M
/F
Age
Com
plet
e ad
(for n
ew p
atie
Nam
e of
re
ferr
ing
heal
th fa
cilit
y D
iagn
osis
Follo
w-
up
1 2
3 R
emar
ks
dres
s
nts)
* If s
putu
m is
for d
iagn
osis
, writ
e a
tick
unde
r dia
gnos
is. I
f the
spu
tum
is fo
r fol
low
-up,
writ
e th
e pa
tient
’s D
istri
ct T
B N
umbe
r und
er fo
llow
-up.
60
Anne
x 4
I. IN
ITIA
L PH
ASE
— P
resc
ribe
d re
gim
enTi
ck fr
eque
ncy:
D
aily
3 tim
es/w
eTi
ck c
ateg
ory
and
indi
cate
num
ber o
f ta
CAT
I
CAT
II
New
cas
e
R
e-tre
atm
ent
(sm
ear-
posi
tive,
or s
erio
usly
ill
smea
r-ne
gativ
e, o
r EP)
HR
Z
E [S
]
HR
Z
E
HR: i
soni
azid
and
rifa
mpi
cin
Z: p
yraz
inam
ide
E:
Tick
app
ropr
iate
box
afte
r th
e dr
ugs
hav
and
dos
ages
ek
blet
s pe
r do
se a
nd d
osag
e of
S (g
ram
s):
C
AT II
I
CA
T IV
N
ew c
ase
Chr
onic
or M
DR
-TB
(
smea
r-ne
gativ
e or
EP)
S
H
R
Z
E
etha
mbu
tol
S: s
trept
omyc
in
e be
en a
dmin
iste
red
TUB
ERCU
LOSI
S TR
EATM
ENT
CAR
D
____
____
____
____
____
____
____
____
____
____
____
____
____
__
Dis
trict
TB
No.
___
____
____
____
____
_ __
____
____
____
____
____
____
____
____
____
____
____
____
____
H
ealth
faci
lity
____
____
____
____
____
_
sup
porte
r (if
appl
icab
le)
____
____
____
____
____
____
____
___
____
____
____
____
____
____
____
____
____
____
____
____
____
Nam
e _
____
____
____
____
____
____
___
Com
plet
e ad
dres
s___
____
____
____
____
_S
ex:
M
F
Age
___
____
___
Nam
e an
d ad
dres
s of
com
mun
ity tr
eatm
ent
____
____
____
____
____
____
____
____
__Di
seas
e si
te
Pul
mon
ary
Extr
apul
mon
ary
(s
peci
fy) _
____
____
__
Type
of p
atie
nt
New
Trea
tmen
t afte
r fai
lure
Rel
apse
Trea
tmen
t afte
r def
ault
Tran
sfer
in
O
ther
(spe
cify
)
___
____
____
___
Resu
lts o
f spu
tum
exa
min
atio
n M
onth
Da
te
Smea
r La
b. N
o.
0
Wei
ght
(kg)
Ple
ase
turn
ove
r fo
r con
tinua
tion
phas
e
9 10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
DAY
1
2 3
4 5
6 7
8
MO
NTH
Num
ber
dose
s thi
s m
onth
Tota
l num
ber
dose
s
give
n
DATE
DO
SES
Dru
gs g
iven
to s
uppo
rter
61
62
Anne
x 5
D
ISTR
ICT
TB R
EGIS
TER
– L
EFT
SID
E O
F TH
E R
EGIS
TER
BO
OK
Ty
pe o
f pat
ient
**
Dat
e of
R
egis
-tra
tion
Dis
trict
TB
No.
N
ame
Sex
M/F
A
ge
Com
plet
e ad
dres
s H
ealth
Fa
cilit
y
Dat
e Tr
eatm
ent
star
ted
Trea
tmen
t ca
tego
ry*
Dis
ease
si
te
P / E
P N
R
F D
T
O
* Ent
er th
e tr
eatm
en
**
Ent
er o
nly
one
code
: C
AT
I: N
ew s
mea
r pos
itive
cas
e, o
r
N: N
ew –
A p
atie
nt w
ho h
as n
ever
had
trea
tmen
t for
TB
or w
ho h
as ta
ken
antit
uber
culo
sis
drug
s
New
cas
e (s
erio
usly
ill s
mea
r neg
ativ
e
for l
ess
than
1 m
onth
. or
ser
ious
ly il
l EP)
R
: Rel
apse
– A
pat
ient
pre
viou
sly
treat
ed fo
r TB
, dec
lare
d cu
red
or tr
eatm
ent c
ompl
eted
, and
who
is
e.g
. 2(H
RZE
)/4(H
R) 3
di
agno
sed
with
bac
terio
logi
cally
pos
itive
(sm
ear o
r cul
ture
)TB
.
C
AT
II: R
e-tre
atm
ent
F:
Tre
atm
ent a
fter f
ailu
re –
A p
atie
nt w
ho is
sta
rted
on a
re-tr
eatm
ent r
egim
en a
fter h
avin
g fa
iled
e
.g. 2
(HR
ZE)S
/1(H
RZE
)/5(H
R) 3
E 3
pr
evio
us tr
eatm
ent.
D: T
reat
men
t afte
r def
ault
– A
pat
ient
who
retu
rns
to tr
eatm
ent,
posi
tive
CA
T III
: New
cas
e (s
mea
r neg
ativ
e or
EP)
bact
erio
logi
cally
, fol
low
ing
inte
rrupt
ion
of tr
eatm
ent f
or 2
or m
ore
mon
ths.
e
.g. 2
(HR
Z)/4
(HR
) 3
T:
Tra
nsfe
r in
– A
pat
ient
who
has
bee
n tra
nsfe
rred
from
ano
ther
TB
Reg
iste
r to
cont
inue
trea
tmen
t.
O
: Oth
er –
All
case
s th
at d
o no
t fit
the
abov
e de
finiti
ons.
Thi
s gr
oup
incl
udes
chro
nic
case
, a p
atie
nt w
ho is
spu
tum
(+) a
t the
end
of a
re-tr
eatm
ent r
egim
en.
t cat
egor
y:
Anne
x 5
D
ISTR
ICT
TUB
ERC
ULO
SIS
REG
ISTE
R –
RIG
HT
SID
E O
F TH
E R
EGIS
TER
BO
OK
R
esul
ts o
f spu
tum
exa
min
atio
n B
efor
e tre
atm
ent
2 or
3 m
onth
s†
5 m
onth
s E
nd o
f tre
atm
ent
Trea
tmen
t out
com
e &
dat
e ††
Dat
e re
sult.
La
b N
o.D
ate
Res
ult
Lab
No.
D
ate
Res
ult
Lab
No.
D
ate
Res
ult.
Lab
No.
C
ure
Com
plet
ed
Failu
re
Die
d D
efau
lt Tr
ansf
er
out
Rem
arks
†CA
T I p
atie
nts
have
follo
w-u
p sp
utum
exa
min
atio
n at
2 m
onth
s; C
AT
II pa
tient
s ha
ve fo
llow
-up
sput
um e
xam
inat
ion
at 3
mon
ths.
††
Ent
er d
ate
in th
e ap
prop
riate
col
umn:
C
ure:
Spu
tum
sm
ear (
+) p
atie
nt w
ho is
spu
tum
(–) i
n th
e la
st m
onth
of t
reat
men
t and
on
at le
ast o
ne p
revi
ous
occa
sion
. Tr
eatm
ent c
ompl
eted
: Pat
ient
who
has
com
plet
ed tr
eatm
ent b
ut w
ho d
oes
not m
eet t
he c
riter
ia to
be
clas
sifie
d as
a c
ure
or a
failu
re.
Trea
tmen
t fai
lure
: Pat
ient
who
is s
putu
m s
mea
r (+)
at 5
mon
ths
or la
ter d
urin
g tre
atm
ent (
also
a p
atie
nt w
ho w
as in
itial
ly s
mea
r (–)
and
bec
ame
smea
r-po
sitiv
e at
2 m
onth
s).
Die
d: P
atie
nt w
ho d
ies
from
any
cau
se d
urin
g th
e co
urse
of t
reat
men
t. D
efau
lt: P
atie
nt w
hose
trea
tmen
t was
inte
rrup
ted
for 2
con
secu
tive
mon
ths
or m
ore.
Tr
ansf
er o
ut: P
atie
nt w
ho h
as b
een
trans
ferr
ed to
ano
ther
reco
rdin
g an
d re
porti
ng u
nit a
nd fo
r who
m tr
eatm
ent o
utco
me
is n
ot k
now
n.
63
Annex 6
QUARTERLY REPORT ON SPUTUM CONVERSION
Patients registered during _____ quarter of year______*
Name of district: ____________________________
District no: _____
Name of District
Signature: _____
Number of new smear positive caregistered in quarecorded above**
Tot
* Quarter: This form that ended 3 monthspatients registered in
** This number shouReport on TB Case
_______
TB Coordinator: ___
_______________
ses rter
Smear noeither 2 or
al converted at 2 or
applies to patients re ago. For example, if the 1st quarter.
ld match the numberRegistration previous
64
________________
_________________ Date of completion of this form:
______________
Sputum conversion at: t done at
3 months 2 months 3 months
3 months:
gistered (recorded in the District Tuberculosis Register) in the quarter completing this form at the beginning of the 3rd quarter, record data on
of new smear positive cases in Block 1, Column 1, of the Quarterly ly completed for patients registered in this quarter.
Annex 7 QUARTERLY REPORT ON TB CASE REGISTRATION
Patients registered during _____ quarter of year______
Name of district: ____ _______________
Name of District TB Coordinator: _____ _______________ Signature: _______________________
District no.: ___ _______
B
Pulmonary
Smear (–) o(2
Sm
<15 years
ear (+) (1)
Block 2. NEW PULMONARY SMBY
Sex 0–14 15–24 25–34
M
F
Block 3. PREVIOUS
Relapse
Treatment aftfailure
* In areas routinely using culture, a separate** Other cases may include patients with unkn
_
_
_
65
_______________
Date of completion of this form: _______________________
lock 1. NEW CASES
r not tested )
Extrapulmonary (3)
>15 years <15 years >15 years
Total (4)
EAR (+) CASES ONLY, FROM BLOCK 1 ABOVE,
SEX AND AGE GROUP
Age group in years
35–44 45–54 55–64 > 65 Total
LY TREATED CASES (Smear-positive)*
er Treatment after default Other**
form for reporting culture-positive patients should be used. own history of previous treatment.
66
Ann
ex 8
Q
UA
RTE
RLY
REP
OR
T O
N T
EATM
ENT
OU
TCO
MES
____
____
____
____
____
_
____
____
____
____
____
__
Nam
e of
Dis
trict
TB
Coo
rdin
ator
:___
____
____
____
___
Sig
natu
re: _
____
____
____
____
____
____
____
____
Patie
nts
regi
ster
ed d
urin
g __
___
quar
ter o
f yea
r ___
___*
D
ate
of c
ompl
etio
n of
this
form
: __
____
____
____
____
___
Trea
tmen
t out
com
es
Tota
l num
ber o
f pu
lmon
ary
patie
nts
regi
ster
ed d
urin
g th
e qu
arte
r re
porte
d on
**
Cur
e
( 1 )
Trea
tmen
t co
mpl
eted
( 2 )
Die
d
( 3 )
Trea
tmen
t fa
ilure
( 4 )
Def
ault
( 5 )
Tran
sfer
out
(a
nd o
utco
me
unkn
own)
( 6 )
Tota
l num
ber
eval
uate
d fo
r ou
tcom
es:
Sum
of c
olum
ns
1 to
6
r (+)
r (–)
ses
men
t fa
ilure
men
t d
efau
lt
app
lies
to p
atie
nts
regi
ster
ed (r
ecor
ded
in th
e D
istri
ct T
uber
culo
sis
Reg
iste
r) in
the
quar
ter t
hat e
nded
12
mon
ths
ago.
For
exa
mpl
e, if
com
plet
ing
this
form
he
3rd
qua
rter,
reco
rd d
ata
on p
atie
nts
regi
ster
ed in
the
2nd
quar
ter o
f the
pre
viou
s ye
ar.
re tr
ansf
erre
d fro
m th
e Q
uarte
rly R
epor
t on
TB C
ase
Reg
istra
tion
for t
he a
bove
qua
rter.
Of t
hese
pat
ient
s, _
____
__ (n
umbe
r) w
ere
excl
uded
from
llo
win
g re
ason
s: _
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
___
y us
ing
cultu
re, a
sep
arat
e fo
rm fo
r cul
ture
-pos
itive
pat
ient
s sh
ould
be
used
.
_
R
Nam
e of
dis
trict
:_ D
istri
ct n
o.:_
____
Type
of c
ase
1.1
Sm
ea
1. New
1.2
Sm
ea
2.1
Rel
ap
2.2
Trea
taf
ter
2. Re-treatment (smear-positive)***
2.3
Trea
taf
ter
*
Qua
rter:
This
form
at th
e be
ginn
ing
of t
** T
hese
num
bers
aev
alua
tion
for t
he fo
***
In a
reas
rout
inel
67
Annex 9 QUARTERLY REPORT ON PROGRAMME MANAGEMENT PART A – DISTRICT LEVEL District name and No. ________________________________ Year ______ Quarter _________ District TB Coordinator ________________________ Date of completion ___________ 1. Number of TB cases registered during the above quarter by treatment status:
Patient’s type
Diagnostic category
Number registered and started treatment
Number registered but not yet treated
Total registered
New smear (+)
Category I
New smear (–) severe forms
Category I
New extrapulmonary severe forms
Category I
Relapse
Category II
Other re-treatment smear (+)
Category II
New smear (–) (less severe forms)
Category III
New extrapulmonary (less severe forms)
Category III
Total
2. Report number of drugs in the district store*:
(HRZE)
H 75, R 150, Z 400, E 275
(HRZ) H 75, R 150, Z 400 mg
(HR) H 150, R 150 g
(HE) H 150, E 400
E 400 mg
S 1 g
Stock on 1st day of the quarter
Amount received from the regional TB coordinator
Amount consumed
Stock on last day of the quarter
* Adapt type of drugs according to your country’s treatment regimens. 3. Consumption of other items during the quarter:
Sputum containers Microscope slides Stock on 1st day of the quarter
Amount received from the regional or central level
Amount used for patients
Stock on last day of the quarter
68
4. Supervisory activities:
Number of health
units in district
Number of health units visited
Number of days spent in supervision
Supervisory visits to health units
5. Sputum examination for case-finding and follow-up by microscopy:
Number of suspects examined by microscopy for case-finding
Number of sputum examinations for case-finding
Number of smear-positive patients discovered
Number of patients examined by microscopy for follow-up
QUARTERLY REPORT ON PROGRAMME MANAGEMENT PART B – REGIONAL LEVEL Region name and No. ________________________________ Year ______ Quarter _________ Regional TB Coordinator ________________________ Date of completion __________ 1. Number of districts in the region involved in the expanded DOTS strategy: Number of districts that started the expanded DOTS strategy during the quarter: _____ Total No. of districts participating in the expanded DOTS strategy at end of the quarter: _____ Total number of districts in the region: _____ 2. No. of Quarterly Programme Management Reports received from participating districts: Received and enclosed: _____ Reports not received from the following districts: District No.: ______________ ______________ _______________ ________________ 3. Supervisory activities: Total No. of supervisory visits by regional coordinator to districts during the last quarter:_____ Number of districts that received supervisory visits at least once during last quarter: _____ Number of districts not visited by regional TB coordinator during the previous quarter: _____ District No.: _______________ _______________ ________________ _______________ 4. Report on number of drugs in the regional store*: (HRZE)
H 75, R 150, Z 400, E 275
(HRZ) H 75, R 150, Z 400 mg
(HR) H 150, R 150
HE H 150, E 400
E 400 mg
S 1 g
Stock on 1st day of the quarter
Amount received from the central unit
Amount distributed to districts
Stock on last day of the quarter
* Adapt type of drugs according to your country’s treatment regimens. 5. Consumption of other items during the quarter: Sputum containers Microscope slides Stock on 1st day of the quarter
Amount received from the central unit
Amount distributed to districts
Stock on last day of the quarter
69
QUARTERLY REPORT ON PROGRAMME MANAGEMENT PART C - NATIONAL LEVEL Year ______ Quarter _________ Date of completion __________ 1. Number of regions in the country involved in the expanded DOTS strategy: Number of regions that started the expanded DOTS strategy during the quarter: _____ Total no. of regions participating in the expanded DOTS strategy at end of the quarter: _____ Total number of regions in the country: _____ 2. No. of Quarterly Programme Management Reports received from participating regions: Received and enclosed: _____ Reports not received from the following regions: Region No.: ______________ ______________ _______________ ________________ 3. Supervisory activities: Total no. of supervisory visits by national supervisors to regions during the last quarter:_____ Number of regions that received supervisory visits at least once during last quarter: _____ Number of regions not visited by national supervisors during the previous quarter: _____ Region No.: _______________ _______________ ________________ _______________ 4. Report on number of drugs in the national store*: (HRZE)
H 75, R 150 Z 400, E 275
(HRZ) H 75, R 150, Z.400 mg
(HR) H 150, R 150
HE H 150, E 400
E 400 mg
S 1 g
Stock on 1st day of the quarter
Amount received
Amount distributed to regions
Stock on last day of the quarter
* Adapt type of drugs according to your country’s treatment regimens. 5. Consumption of other items during the quarter: Sputum containers Microscope slides Stock on 1st day of the quarter
Amount received
Amount distributed to regions
Stock on last day of the quarter
70
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Annex 10
For use by facility to which patient has been referred or transferred: Name of facility ______________________________________________ District __________________________ Date ____________________ Name of patient __________________________District TB No. _______________
The above patient reported at this facility on ________________________________(date)
Signature ___________________________Position________________________ Send this part back to referring/transferring facility as soon as patient has reported.
TUBERCULOSIS REFERRAL/TRANSFER FORM
(Complete top part in triplicate) Tick and comment to indicate the reason for this referral or transfer:
� Referral to register and begin TB treatment
� Referral for __________ ____________________ ____________________
� Transfer (registered patient is moving)
Name/address of referring/transferring facility____________________________________________________________ _________________________________________________________________ Name/address of facility to which patient is referred/transferred ______________________ ___________________________________________________________________
Name of patient __________________________ Age _______ Sex: M � F �
Address (if moving, future address) _______________________________________
_________________________________________________________________
Name and address of contact person for patient _________________________________
_______________________________________________________________________
Diagnosis*______________________________________________________________
District TB No.* __________________ Date treatment started*____________________
Category of treatment:* � CAT I New case, smear-positive � CAT II Re-treatment � CAT III New case, smear-negative or extrapulmonary � CAT IV Chronic or MDR-TB Drugs patient is receiving ______________________________________________ ___________________________________________________________________ Remarks (e.g. side-effects observed) _____________________________________ ____________________________________________________________________ ______________________________________________________________ Signature ___________________ Position _________ Date of referral/transfer_______
*Complete if known. If this is a referral for diagnosis, these items may be unknown.