Form 1.

Presumptive TB Masterlist

Name of Facility: 

Province/ HUC: 

Region: 

Cohort: 
 PRESUMPTIVE TB?
Complete Address Name of Referring Facility/ Unit/ Mode of Presumptive Presumptive
Date of Consult Patient’s Full Name Age Sex Screening
and Contact Number Physician/ Health worker DS-TB DR-TB

MM/DD/YYYY SURNAME, Given Names Name Extension and Middle Name M/ F P/A/I/E Check [] one
(1) (2) (3) (4) (5) (6) (7) (8)

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Form 1. Presumptive TB Masterlist  v. 050120

 Sputum Examination Diagnosis
Smear Microscopy Chest X-ray Tuberculin Skin Test Remarks
Xpert MTB/RIF Active TB TB Infection Not TB Action Taken/
or TB LAMP
Referred To and Status Type of Specimen if Presumptive EP-TB,
Result (see legend) and Result/ Impression and Date of Result and Date of Examination Date Notified (MM/DD/YYYY)
Date of Collection (MM/DD/YYYY) Examination (MM/DD/YYYY) (MM/DD/YYYY) and Case Number  Other Diagnostic Tests,
TB Case Number of Index, etc.
(9) (10) (11) (12a) (12b) (12c) (13) (14)

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Form 1. Presumptive TB Masterlist  v. 050120

 Mode of Number Number of Mode of Number Number of
Screening Remarks Screening Remarks
Date/s Screened by Presumptive Date/s Screened by Presumptive
target risk groups, target area, organizer target risk groups, target area, organizer
A/ I CXR TB Identified A/ I CXR TB Identified

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Form 1. Presumptive TB Masterlist  v. 050120

 Field Definition Format or Legend
1 Date of Consult Date patient was seen or identified as a presumptive TB All dates in MM/DD/YYYY
2 Patient's Full Name Patient's legal full name SURNAME in capital letters, Given Names, Name Extension, and Middle Name
3 Age Patient's completed years as of date of consult NN in years if at least 1 year old; NNm (for completed months) if less than 0
4 Sex Patient's sex M - male; F - female
House Number, Street and Village Name, and Baranggay/ District if patient is within facility's catchment;
Complete Address and Patient's contact information for tracking and follow-up
5 Otherwise, put complete address including Municipality, City, Province, and Zip Code
Contact Number purposes
Mobile Number 09xx-xxxxxxx and Landline Number xxxx-xxxx; add area code if patient is from outside the facility's catchment
Name of Referring Facility/ Unit/ Name of Facility, Unit, Physician, or Health worker that
6 WI if walk-in; Identifying name of facility, unit, physician, or healthworker that/ who referred the patient
Physician/ Health worker referred patient
7 Mode of Screening Approach done in finding the patient (choose one only) P - Passive Case Finding; A - Active Case Finding; I - Intensive Case Finding; E- Enhanced Case Finding
Presumptive DS-TB
Patient's risk classification based on interview (choose one
8 Presumptive TB? Presumptive DR-TB - high risk for MDR-TB (previously treated for TB, new TB cases that are contacts of confirmed DR-TB cases, or non-
only)
converter among patients on DS-TB regimens)
Laboratory tests done to test the patient's sputum (fill-up
If extra-pulmonary, indicate type of specimen in Remarks column
all that apply)
T - MTB detected Rifampicin resistance not detected, RR - MTB detected Rifampicin resistance detected,
Xpert MTB/RIF Test Result and Date of Sputum
TI - MTB detected, Rifampicin resistance indeterminate, N - MTB not detected, I - Invalid/ No result/ Error; Not Done
Collection
Date in MM/DD/YYYY
0 - no AFB seen / no AFB onserved in 1 length
+n - n AFB seen in 1 length / 5-49 AFB in 1 length / 3-24 AFB in 1 length
9 Sputum Examination 1+ - 10-99 AFB seen in 1 length / 3-24 AFB in 1 field / 1-6 AFB in in 1 field
Smear Microscopy Test Result and Date of Sputum
2+ - 1-10 AFB/ OIF, at least 50 fields / 25-250 in 1 field / 7-60 in 1 field
Collection
3+ - >10 AFB/ OIF, at least 20 OIF / > 250 in 1 field / >60 in 1 field
Not Done or N/A
Date in MM/DD/YYYY
P - MTB detected, the sample fluoresce under the UV light
N - MTB not detected, the sample did not fluoresce under the UV light
TB LAMP Test Result and Date of Sputum Collection
I - Sample with incomplete fluorescence as compared to the positive control
Date in MM/DD/YYYY
CXR impression unless facility physician requires otherwise; Indicate “Not Done” or “Not Available” as applies
10 Chest X-ray Chest X-ray Results and Date of Examination
Date in MM/DD/YYYY
NN in mm; Indicate “Not Done” or “N/A” as applies
11 Tuberculin Skin Test Turbeculin Skin Test Results and Date of Examination
Date in MM/DD/YYYY
12 Identification of the patient's illness (choose one only)
12a if Active TB Disease, Date of Notification Indicate date in MM/DD/YYYY Record 4a for Notification only, 4b for DS-TB, or 4c if DR-TB was opened and TB Case Number
Diagnosis
12b if TB Infection, Date of Notification Indicate date in MM/DD/YYYY Record 4d was opened and TPT Case Number, Put a check mark if treatment was not started
12c if Not TB Put a check mark
Indicate name of facility/unit/physician where patient was referred to, date of referral in MM/DD/YYYY and outcome of referral
Action Taken/ Referred To Post-diagnosis actions taken including referral to another
13 (accepted or lost)
and Status facility
If Masterlist is used as a Hospital Referral Logbook, indicate here reason/s of referral
Type of specimen collected if Presumptive EP-TB;
14 Remarks Other notes on the patient if close contact, indicate TB Case Number of Index;
if Other Diagnostic Test is available indicate name of test, date of examination in MM/DD/YYYY and results including unit of measure
Form 1. Presumptive TB Masterlist  v. 050120