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Introduction to the FormsJulie Tomaro, BSN
Washington State Department of Health
INTERJURISDICTIONAL TB NOTIFICATION (IJN) TRANSFER AND
FOLLOW-UP FORMS
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IJN Forms Online
The forms can be found on the National TB Controller’s Website at
www.tbcontrollers.org/resources/interjurisdictional-transfers
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IJN Transfer Form
--Within 7 DaysWithin 30 DaysFinalOther
Page One: Top
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IJN Transfer Form
--AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelaware
--StateCountyOther
--Within 7 DaysWithin 30 DaysFinalOther – See right
Page One: Middle
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IJN Transfer Form
--FM
--YesNoUnknown
--American IndianAlaskan NativeAsianBlack or African American
--United StatesSee Comments - Page 3___AbkhaziaAfghanistan
--HomeCellWork
--YesNo
Page One: Bottom
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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
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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
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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
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IJN Transfer FormPage Two: Section 4
--Treatment started – See Section 5Needs treatmentN/A
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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
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IJN Follow-up Form
--7 Day30 DayFinalOther:
Active/ Suspect TBContact Class A/BTB Infection
First Quarter
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IJN Follow-up FormSecond Quarter
--FM
--YesNoUnknown
--American IndianAlaskan NativeAsianBlack or African American
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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
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IJN Follow-up Form
--Completed TreatmentNot TB Infection/DiseaseNever LocatedLostDiedRefusedMovedOther – See right
--YesNo
Fourth Quarter
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Wrap Up
NTCA/NTNC Interjurisdictional Transfers:http://www.tbcontrollers.org/resources/interjurisdictional-transfers/
Please submit any questions or comments about the form to [email protected]