Introduction to the FormsJulie Tomaro, BSN

Washington State Department of Health

INTERJURISDICTIONAL TB NOTIFICATION (IJN) TRANSFER AND

FOLLOW-UP FORMS

IJN Forms Online

The forms can be found on the National TB Controller’s Website at

www.tbcontrollers.org/resources/interjurisdictional-transfers

IJN Transfer Form

--Within 7 DaysWithin 30 DaysFinalOther

Page One: Top

IJN Transfer Form

--AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelaware

--StateCountyOther

--Within 7 DaysWithin 30 DaysFinalOther – See right

Page One: Middle

IJN Transfer Form

--FM

--YesNoUnknown

--American IndianAlaskan NativeAsianBlack or African American

--United StatesSee Comments - Page 3___AbkhaziaAfghanistan

--HomeCellWork

--YesNo

Page One: Bottom

IJN Transfer Form

--PulmonaryExtrapulmonaryPulmonary and extrapulmonary

--Treatment started – See Section 5Needs treatment

--PositiveNegativeUnknownN/ANot done

--PositiveNegativeUnknownN/ANot done

--PansensitiveINH resistantRIF resistantEMB resistantPZA resistantMultidrug resistantOther – See attached results

--YesNoUnknown

Page Two: Section 1

IJN Transfer Form

--HighMedium/closeLow/other-than-close

--TSTQFT-GITT-SpotNeeds testingN/AOther

--NegativePositiveIndeterminantBorderlineNot done

--AttachedNot donePendingNeeds x-ray

--Treatment started – See Section 5Needs treatmentWindow prophylaxis started – See Section 5Needs window prophylaxisN/A

Page Two: Section 2

IJN Transfer Form

--A – Active pulmonaryB1 – Noninfectious pulmonaryB2 – Noninfectious extrapulmonaryB3 – TB infectionB4 – TB contact

--YesNo

Page Two: Section 3

--Results attachedNeeds testN/A

--Results attachedNeeds sputaN/A

--Treatment started – See Section 5Needs treatmentN/A

IJN Transfer FormPage Two: Section 4

--Treatment started – See Section 5Needs treatmentN/A

IJN Transfer Form

--Active/suspect TBTB infectionWindow prophylaxis

--IsoniazidRifampinPyrazinamideEthambutolStreptomycinRifabutinRifapentineEthionamideAmikacin

--Daily DOTDaily SAT5x weekly DOT5x weekly SAT3x weekly DOT3x weekly SAT2x weekly DOT2x weekly SAT1x weekly DOT1x weekly SATOther- See attached MAR

--YesNoUnknown

--YesNo

Page Three: Section 5

--Yes – See attached notesNoUnknown

IJN Follow-up Form

--7 Day30 DayFinalOther:

Active/ Suspect TBContact Class A/BTB Infection

First Quarter

IJN Follow-up FormSecond Quarter

--FM

--YesNoUnknown

--American IndianAlaskan NativeAsianBlack or African American

IJN Follow-up Form

--InitiatedCompletedNot DoneReferredN/A

--No Infection/DiseaseTB InfectionActive DiseasePendingUnknownN/A

--ContinuingStartedStoppedNot startedCompleteReferredN/A

Third Quarter

--States--AlabamaAlaska

--PansensitiveINH resistantRIF resistantEMB resistantPZA resistantMDROther – See commentsOther – See attached results

--QFTT-Spot

IJN Follow-up Form

--Completed TreatmentNot TB Infection/DiseaseNever LocatedLostDiedRefusedMovedOther – See right

--YesNo

Fourth Quarter

Wrap Up

NTCA/NTNC Interjurisdictional Transfers:http://www.tbcontrollers.org/resources/interjurisdictional-transfers/

Please submit any questions or comments about the form to ntca@tbcontrollers.org