Maharashtra Knowledge Corporation material NOTICE TB Office.pdfNIKSHAY ID CDL NIKSHAY ID PMDT NIKSHAY ID PMDT TB No. Reason for Testing New Previously Treated Presumptive TB Private

RNTCP Request Form for examination of biological specimen for TB (Required for Diagnosis of TB, Drug Sensitivity Testing and follow up)

Patient InformationPatient name Age (in yrs):____ Gender: M F TG

Patient mobile no. or other contact no.

Specimen date ofcollection (DD/MM/YY) _______

Sputum Other (specify)______

Aadhar no.

Patient address with landmark

HIV Status: Reactive Non-Reactive Unknown

Key populations:Contact of known TB Patient Diabetes Tobacco Prison Miner Migrant Refugee Urban slum Health-care worker Other(specify) ______

Reason for Testing:Diagnosis and follow up of TB

Diagnosis (NIKSHAY ID_________________) Follow up (Smear and culture)

H/O anti TB Rx for >1 month: Yes No RNTCP TB Reg No ______________NIKSHAY ID:________________Regimen: New Previously TreatedReason: End IP End CPPost treatment: 6m 12m 18m 24m

Presumptive TB Repeat Exam Private referral Presumptive NTM

Predominant symptom __________________

Duration ______ days

Diagnosis and follow up Drug-resistant TB

Drug Susceptibility Testing (DST) Follow up (Culture)

Presumptive MDR TB

New Previously treated PMDT TB No ____________DR TB NIKSHAY ID: _______________

Regimen: Regimen for INH mono/poly resistant TB Regimen for MDR/RR TB Shorter regimen* Modified Regimen for MDR/RR-TB + FQ /SLI resistance Regimen for XDR TB Modified Regimen for mixed pattern resistance Regimen with New Drug for MDR-TB Regimen + FQ/SLI resistance Regimen with New Drug for XDR-TB Regimen with New Drug for failures of regimen for MDR TB Regimen with New Drug for failures of regimen for XDR-TB Regimen with New Drug for mixed pattern resistance

Treatment Month Week :____________

At diagnosis Contact of MDR/RR TB Follow up Sm +ve Private referral Discordance resolution

Presumptive H mono/poly

Presumptive XDR TB

MDR/RR TB at Diagnosis ≥ 4 months culture positive 3 monthly for persistent culture positives (treatment month _____) Culture reversion Failure of MDR/RR-TB regimen Recurrent case of second line treatment Discordance resolution

Test requested: Microscopy TST IGRA Chest X-ray Cytopathology Histopathology CBNAAT Culture DST Line Probe Assay Gene Sequencing Other (Please Specify) ____________________

Requestor Name, Designation and Signature: ________________________________________Contact Number:________________ Email ID:______________________

Results: NIKSHAY ID Generated: ______________________ CDL NIKSHAY ID: _______________

Microscopy ( ZN Florescent)

Lab Sr. No Visual appearanceResult

Negative Scanty 1+ 2+ 3+Sample ASample B

Date tested: ______________ Date Reported:_______________ Reported by:______________________ (Name and Signature)

Name and Type of referring facility (PHI/DMC/TU/ DTC/ICTC/ART/Medical College/DR-TB Centre/Private Others, specify): __________________________Health Establishment ID (NIKSHAY): _ _ _ _

CDL NIKSHAY ID: _ _ - _ _ _ - _ - C - _ _- _ _ _ _ _RNTCP TB Reg No. __________________ Or

☐ Not Applicable

State: _____________________ District:_______________ Tuberculosis Unit (TU): _________________

Drug Susceptibility Test (DST) results

Lab Sr.No1st line drugs SLI FQ Other

R H

(inhA

)

H

(kat

G)

S E Z Km

Cm

Am

Lfx

Mfx

(0

.5)

Mfx

(2

)

Eto

PA

S

Lzd

Cfz

Clr

Azi

Date Result: ______________ Date Reported:_______________ Reported by:________________________ R: Resistant; S: Susceptible; C: Contaminated; -- Not done (Name and Signature)

Other tests for TB diagnosisTest (Please Specify): ______________________Result:__________________________________________________________________________________________________________________________________________________________________________Date reported:_______________ Reported by:_______________________ (Name and Signature)

Cartridge Based Nucleic Acid Amplification Test (CBNAAT)Sample A B M. Tuberculosis Detected Not Detected N/ARif Resistance Detected Not Detected Indeterminate N/A Test No Result Invalid Error – Error Code________ (Please arrange for fresh sample)

Date tested: ______________ Date Reported:_______________ Reported by:_______________________ (Name and Signature)

Culture ( LJ LC)Lab Sr. No Negative Positive NTM (write species) Contamination

Date Result: ______________ Date Reported:_______________ Reported by:_______________________ (Name and Signature)

Line Probe Assay (LPA) Direct Indirect Lab serial ___________

First line LPARpoB: ---- locus control: � present � absent

WT1: �present � absent WT2: � present � absent WT3: � present �absent WT4: � present � absent

WT5: � present � absent WT6: � present �absent WT7 : � present �absent WT8 : � present � absent

MUT1 (D516V): � present �absent MUT2A (H526Y): � present �absent MUT2B (H526D): � present �absent MUT3 (S531L): � present �absent

Kat G: ----- locus control: � present � absent

WT1 (315): � present � absent

MUT1 (S315T1): � present � absent MUT2 (S315T2): � present � absent

Inh A:----- locus control: �present �absent

WT1 (-15, -16): � present � absent WT2 (-8): � present � absent

MUT1 (C15T): � present � absent MUT2 (A16G): � present � absent MUT3A (T8C): � present � absent MUT3B (T8A): � present � absent

Second line LPAgyrA:--

locus control: � present � absent

WT1 (85-90): � present � absent

WT2 (89-93): � present � absent

WT3 (92-97): � present � absent

MUT1 (A90V): � present � absent

MUT2 (S91P): � present � absent

MUT3A (D94A): � present � absent

MUT3B (D94N/Y): � present � absent

MUT3C (D94G): � present � absent

MUT3D (D94H): � present � absent

gyrB:----

locus control: �present �absent

WT1 (536-541): � present � absent

MUT1 (N538D): � present � absent

MUT2 (E540V): � present � absent

rrs:-----

locus control: �present �absent

WT1 (1401-02): � present � absent

WT2 (1484): � present � absent

MUT1 (A1401G): � present � absent

MUT2 (G1484T): � present � absent

eis:-----

locus control: �present �absent

WT1 (37): � present � absent WT2 (14, 12, 10): � present �

absent WT3 (2): � present � absent

MUT1 (C-14T): � present � absent

Final LPA Interpretation: ---

MTB result � MTB positive � MTB Negative RIF � Sensitive � Resistant � Indeterminate INH �Sensitive �Resistant � Indeterminate Quinolone � Sensitive � Resistant � Indeterminate SLID �Sensitive �Resistant � Indeterminate

Date Result: ______________ Date Reported:_______________ Reported by:________________________ (Name and Signature)

REFERRAL SLIP (Referring health facility copy)

Date: …………Lab referred to:….………………..Name of referring HF: ………………………………..Name of Patient: ………………………………………….. Age: ……… years Sex: M / F / TGAddress of patient (with landmarks)

……………………………………………………………………..

……………………………………………………………………

……………………………………………………………………Patient’s / Contact person’s Mobile number : __________________________________Kindly tick

Cough……………………..daysFever……………………..daysLoss of weight ……………………..daysNight sweat ……………………..daysBlood in sputum/ cough ………………days

Contact of TB / MDR TB

Stamp of HF Referred by (Name & Sign)

REFERRAL SLIP(Patient copy)

Date: …………Lab referred to:….………………..Name of referring HF: ………………………………..Name of Patient: ………………………………………….. Age: ……… years Sex: M / F / TGAddress of patient (with landmarks)

……………………………………………………………………..

……………………………………………………………………

……………………………………………………………………Patient’s / Contact person’s Mobile number : __________________________________Kindly tick

Cough……………………..daysFever……………………..daysLoss of weight ……………………..daysNight sweat ……………………..daysBlood in sputum/ cough ………………days

Contact of TB / MDR TB

Stamp of HF Referred by (Name & Sign)

REFERRAL SLIP(Lab Copy)

Date: …………Lab referred to:….………………..Name of referring HF: ………………………………..Name of Patient: ………………………………………….. Age: ……… years Sex: M / F / TGAddress of patient (with landmarks)

……………………………………………………………………..

……………………………………………………………………

……………………………………………………………………Patient’s / Contact person’s Mobile number : __________________________________Kindly tick

Cough……………………..daysFever……………………..daysLoss of weight ……………………..daysNight sweat ……………………..daysBlood in sputum/ cough ………………days

Contact of TB / MDR TB

Stamp of HF Referred by (Name & Sign)

SR No. _____ ____________

SR No. _____ ____________

SR No. _____ ___________

NIKSHAY ID. _____ ____________ NIKSHAY ID. _____ ____________ NIKSHAY ID. _____ ____________

REVISED NATIONAL TUBERCULOSIS CONTROL PROGRAMMETreatment Card TB Notification No / NIKSHAY ID ______________

State:______________________ City / District: ___________ TB Unit:_____________ PHI: _____________ Area: Tribal / Rural / Urban / Urban slum

Name: ______________________Sex: M F TG Age: ____ Marital status: _______ Occupation:_____________ Socioeconomic status: APL/ BPLComplete Address: House No. _______ Road: ___________ Important landmark: __________________ Ward/Village: __________ Town/City: _______ Taluka/Mandal:______Pin code: ______ Mobile:__________ Aadhaar No.: _______ Key population: Contacts / Miners / Refugees / Migrants / Prison inmatesName and Address of contact person ______________________________________________________ Mobile No. __________________________

Name of Treatment Supporter _________________________________________Designation ______________Mobile No.: _________________________Initial home visit by _______________ Date________ Type of Treatment Adherence – DOT / Family DOT / ICT supported, specify _______ / Other ______Predominant symptom _________ Duration _________day Number of health care providers visited before diagnosis for current episode: ________

H/O of Previous ATT: ___ months of treatment ___ months since end of last episodeSource of treatment: Public Private Previous regimen: _____________

Initial weight of patient: _____ kg height _____ cm

<6yrs >6yrs No of children less than 6 years given chemoprophylaxis = _____

No. of household contacts

Name Wt(Kg)

Dose(mg)

1 2 3 4 5 6

No. screenedNo. with symptoms No. evaluatedNo. diagnosed No. put on treatment

Addiction related information Current Tobacco user Yes NoIf yes, Smoking Smokeless Linked for cessation Yes NoIf tobacco user, status of tobacco use at end of treatment Quit Not quitH/o Alcohol intake Yes NoIf yes, linked for deaddiction Yes No

Investigations(ZN / FM / CBNAAT/ Liquid C / Solid C)

Date LabLab. No.

Test result

Sample sent to CDST

(date)

DSTresult

Pre-treatment

End of Intensive Phase

End of treatment

Site of disease

Pulmonary Extra PulmonarySite ______________

Type of Patient New Recurrent Transferred in Treatment After Failure Treatment after Others, previously lost to followup treated (Specify)_____

Case Definition Microbiologically confirmed Clinically diagnosed TB

HIV related information

HIV Status: Unknown Reactive NR Date_____ PID_____

CPT delivered on: (1) (2) (3) (4) (5) (6)

Initiated on ART: No Yes Date & ART No._____

Diabetes related information

Diabetes Status: Unknown Diabetic Non-Diabetic

RBS_____ FBS_____ End IP____ End treatment____

Initiated on ADT: No Yes Date & ADT No._____

Other co-morbidityDetails ___________________________________________

Signature of MO with date _____________________

Other investigations (if any) with date and result

Regimen – New / Previously Treated Date of initiation of intensive phase _________ Date of initiation of continuation phase ____________Dosage frequency Daily Intermittent Drug formulations FDC Combipack Loose drugs Drug packaging PWB Strips

Weight Band: Adult: 25-39 Kg 40-54 Kg 55-69 Kg ≥70 Kg Pediatric: 4-7 Kg 8-11 Kg 12-15 Kg 16-24 Kg 25-29 Kg 30-39 Kg

Dosages: FDC / Combipack ______ per day Weight _________ (kg) Height_________ (cm)

Mark when doses are taken under direct observation, when the dose was not observed, O when missed the doseRecord CP from fresh lineMonth/year

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Wt

Retrieval Actions for Missed Dose Details of Adverse events

DateBy

WhomWhom

contacted

Reason for missed doses

Outcome of retrieval action

Date of adverse

event

Details of symptoms

Action takenDuration of

management for adverse event

Outcome of adverse event

Post treatment follow up clinical & sputum (Results with date)Follow up Clinical CXR Smear Culture Impression6 mths of Rx12 mths of Rx18 mths of Rx24 mths of Rx

Treatment outcome with date: ______________ Signature of the MO with date: _____________

Loose drugs

DosePills

H R Z E S

Remarks______________________________________________________________________________________________________________________

Nutrition support (if any, give details)

RNTCP TB identity card

Name: __________________________________________________________

Sex M F TG Age:____________

Address:_________________________________________________________

________________________________________________________________

Contact No: _________________ Aadhar ID. ___________________________

PHI __________ TU _____________ District __________

NIKSHAY ID:__________________________

Name and designation of treatment

supporter:_____________________________

_____________________________________

Contact number and address of treatment

supporter:-____________________________

_____________________________________

CPT ART Diabetic Smoker

Date of starting treatment: (DD/MM/YYYY)

Site of Disease

Pulmonary

Extra pulmonary

Case Definition

Microbiologically confirmed

Clinically diagnosed

Treatment regimen:

New

Previously treated

Type of Patient

New

Recurrent

Treatment after Lost to

Follow up

Treatment after Failure

Other Previously treated

Transferred in

Weight Band:

Adult: 25-39 Kg 40-54 Kg 55-69 Kg ≥70 Kg

Pediatric: 4-7 Kg 8-11 Kg 12-15 Kg 16-24 Kg 25-29 Kg 30-39 Kg

Sputum results

Smear Date Smear Result Culture Date Culture Result

Diagnosis

End IP

End RX

6 months

12 months

18 months

24 months

Appointment dates

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________In case of side effects or queries please contact

Name and contact number:______________________________________ __________________________________________________________

Treatment outcome: _________________________ Date:____________

RNTCP PMDT Treatment Book

Patient’s name: _____________________________________________

Age: _______yrs Gender: Male Female Transgender

Address: __________________________________________________

_________________________________________________________

Marital status: ______________ Occupation: ____________________

Contact No: _______________________________________________

Aadhar ID ________________________________________________

Name, designation of treatment supporter:_________________________

__________________________________________________________

_________________________________ Contact no:_______________

State:__________________ District: ___________________________

TB Unit: ________________ PHI:_____________________________

Initial home visit: Date _______________ By:_____________________

DR TB Centre:____________ District __________ State ___________

NIKSHAY ID CDL NIKSHAY ID PMDT NIKSHAY ID PMDT TB No

Reason for Testing

New Previously Treated

Presumptive TB Private Referral Presumptive NTM

Presumptive

MDR TB

At diagnosis

Contact of MDR/RR TB

Follow up Sm+ve at end IP

Private referral

Presumptive H mono/poly

Presumptive

XDR TB

MDR/RR TB at diagnosis

4 months culture positive

3 monthly, for persistent culture positives (treatment month __)

Culture reversion

Failure of MDR/RR-TB regimen

Recurrent case of second line treatment

Drug Susceptibility Test (DST) results

Date of sample collection R H

(in

hA

)H

(ka

tG)

S E Z Km

Cm

Am

Lfx

Mfx

(0.

5)

Mfx

(2)

Eto

*P

AS

*Lz

dC

fz*

Clr*

Azi

*B

dq*

Dlm

*

R: Resistant; S: Susceptible; C: Contaminated; -- Not done *whenever available

Contact Investigation

No of members screened

No of presumptive TB cases identified

No of presumptive TB cases evaluated

No diagnosed with TB

No of DR-TB diagnosed

DR-TB Centre Committee meetings – dates and decisions

Date Decision Duration of indoor stay

TB Site: Pulmonary Extra Pulmonary

If extra pulmonary, please specify ____________________

Treatment regimen

Regimen for INH mono/poly resistant TB Regimen for MDR/RR TB Shorter Regimen Modified Regimen for MDR/RR-TB + FQ/SLI resistance Regimen for XDR TB Modified Regimen for mixed pattern resistance Regimen with New Drug for MDR-TB Regimen + FQ/SLI resistance Regimen with New Drug for XDR-TB Regimen with New Drug for failures of regimen for MDR-TB Regimen with New Drug for failures of regimen for XDR-TB Regimen with New Drug for mixed pattern resistance

Initiation Date: __________________ Registration Date: _______________

Initial Weight: ________kgs Height:_________cms

Weight band:

Conventional - <16 Kg 16-25 Kg 26-45 Kg 46-70 Kg >70 Kg

Shorter regimen - <30 Kg 30-50 Kg >50 Kg

Drug and DosagesDrugs Dose (mg)HREZKmAmCmLfxMfxCsEtoPASLzdCfzAmx ClvClrBDQ

Patient eligible and consented for New Drug* Yes No

If No, reason________________________________________________________

Name & Signature of Treating Physician:

______________________________________________

*Whenever available

Month of

Treatment

Culture Results Other Investigations

Date Lab No Culture S. Cr LFT ECG*-QTC

Interval

CBC/

Platelets

Electrolyte (K,

Mg, Ca)

Urine

Gravindex

Diagnosis

1st

week

2nd

week

3rd

week

4th

week

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

29

30

31

32

33

34

35

* ECG to be done daily (first two weeks), weekly (for 3 months) then monthly

Drug Susceptibility Testing (DST) Results

Drug

Date of specimen collection & type of DST (LJ/LC/LPA/CBNAAT)

Month___ Month___ Month___ Month___ Month___ Month___

R

H

(inhA)

H2

(katG)

S

E

Z

Km

Cm

Am

Lfx

Mfx

(0.5)

Mfx

(2.0)

Eto

PAS

Lzd

Cfz

Patient’s Name:_________________________

Blood Sugar Testing:

Date:___________

RBS:__________

FBS:____________

ADT*

(*write date of starting)

Thyroid Function Test

Month Zero Six

Date

T3

T4

TSH

Date of starting intensive phase: ______________________

Date of starting continuation phase:______________________

Details of change

Date Changed regimen Reason for change

ADMINISTRATION OF DRUGS (one line per month)

Month

& Yr

Day Wt

in

Kg1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Mark in the boxes: = directly observed; Unsupervised; = drugs not taken; X = initiation of new box;

Recording of CP should start from fresh line.

Month

& Yr

Day Wt

in

Kg1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Mark in the boxes: = directly observed; Unsupervised; = drugs not taken; X = initiation of new box;

Recording of CP should start from fresh line.

Month

& Yr

Day Wt

in

Kg1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Mark in the boxes: = directly observed; Unsupervised; = drugs not taken; X = initiation of new box;

Recording of CP should start from fresh line.

Month

& Yr

Day Wt

in

Kg1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Mark in the boxes: = directly observed; Unsupervised; = drugs not taken; X = initiation of new box;

Recording of CP should start from fresh line.

Date of

retrieval

action

By whom

Who

contacted

Reason for

missed doses

Outcome of retrieval

action

Date of

adverse drug

reaction

Details of symptoms Action taken

Clinical Notes

Date of visit:

Chief Complaints:

Clinical examination (major findings) :

Counselling notes:

Weight

Investigations

Treatment

Clinical Notes

Date of visit:

Chief Complaints:

Clinical examination (major findings) :

Counselling notes:

Weight

Investigations

Treatment

Clinical Notes

Date of visit:

Chief Complaints:

Clinical examination (major findings) :

Counselling notes:

Weight

Investigations

Treatment

Clinical Notes

Date of visit:

Chief Complaints:

Clinical examination (major findings) :

Counselling notes:

Weight

Investigations

Treatment

Clinical Notes

Date of visit:

Chief Complaints:

Clinical examination (major findings) :

Counselling notes:

Weight

Investigations

Treatment

Clinical Notes

Date of visit:

Chief Complaints:

Clinical examination (major findings) :

Counselling notes:

Weight

Investigations

Treatment

Treatment outcome Date Remarks

Cured

Treatment completed

Died

Failed – Culture non conversion

Failed – Culture reversion

Failed – Additional drug resistance

Failed – Adverse Drug Reaction

Lost to follow up

Regimen Change

Not evaluated

In remarks column, provide cause of death, reason for lost to follow up, latest TB

no. in case of failure and put on treatment further

Post treatment follow up clinical & sputum (Result with date)Follow up Clinical Smear Culture CXR Impression

6 months of Rx

12 months of Rx

18 months of Rx

24 months of RX

REVISED NATIONAL TUBERCULOSIS CONTROL PROGRAMME Referral / Transfer form for treatment Serial Number

To be filled in triplicate. One copy to be sent to the DTO receiving the patient, one copy to the health facility where the patient is referred to, and one copy to the patient

Name and address of referring health facility ___________________________________________________

Contact Number and e-mail address of referring health facility: ___________________________________

Name and address of health facility to which patient is referred ___________________________________ __________________________________________________________________________________________

Name of patient__________________ Age________________ Sex M F TG

Complete Address__________________________________________________________________________

_________________________________________________________ Contact no. ____________________

Patient detail

Site of disease

Pulmonary Extra Pulmonary, Site ______________

Type of Patient New Recurrent Transferred in Treatment After Failure Treatment After Others, previously treated Lost to Follow-up (Specify)________

Case DefinitionMicrobiologically confirmed Clinically diagnosed

H/O of ATT: ___ months of treatment

___ months since end of last episode

Diagnosis detailsDate of diagnosis: __/__/___ Name of laboratory: Type of test: ZN / FM / CBNAAT / CultureResult : TB notification number:

HIV Status: R NR UnknownDST Status: Rif Sensitive Rif Resistant Unknown, if unknownSample sent for DST to ______________Date: __/__/__

Treatment regimen: New Previously Treated

Date of treatment initiation: : __/__/__ Number of doses:_____________________

Referred for: Initiation of treatment

Adverse drug reaction (give details) ____________________________________________

Transfer out (give details)____________________________________________________

Any other (give details)______________________________________________________

Name and designation of the referring doctor_______________________________________________

Date referred

-------------------------------------------------------------------------------------------------------------------------- Serial Number____________________________

For use by the health facility where the patient has been referred

Name of receiving health facility___________________ Name of TB Unit and District__________________

Name of patient __________________ TB No (if available) ________________________

Age__________ Sex M F TG Date of receipt of patient______________________

Date of initiation of treatment _____________________ Treatment regimen __________________________

Result of End IP specimen examination _____________ Date of end IP specimen examination ___________

Treatment outcome ______________________ Date of treatment outcome ____________________

Signature Designation _____

Date___________________________________

This portion of the form has to be sent back to the referring unit as soon as the patient has been initiated on RNTCP treatment

RNTCP PMDT Treatment Register

Month ________Quarter ________ Year ___________ District: ________________ C-DST Lab: ____________ DR-TB Centre:_______________ State: _______

PM

DT

TB

No

NIK

SH

AY

ID

PM

DT

NIK

SH

AY

ID

CD

L N

IKS

HA

Y ID Patient’s

name in full

Gen

der

(M/F

/TG

)

Age

in y

rs

Complete address & mobile number

Name of health

facility, TU, district

@ R

eas

on f

or T

estin

g

Site

of

Dis

ease

(P

/EP

) Type (New,

Recurrent, TALFU, Failure, Others)

DST Details

Typ

e (L

J/LC

/ LP

A/

CB

NA

AT

)

Dat

e of

DS

T

Results

R H(in

hA

)

H(k

atG

)

S E Z Km

Cm

Am

Lfx

Mfx

(0.

5)

Mfx

(2)

Eto

PA

S

Lzd

Cfz

@ Presumptive TB – 1; Private referral – 2; Presumptive NTM – 3;

@ Presumptive MDR TB, At diagnosis–4; Contact of MDR/RR TB – 5; Follow up Sm +ve at end IP – 6; private referral – 7; Discordance resolution – 8; Presumptive H mono/poly – 9; MDR/RR TB at diagnosis – 10; ≥ 4 months culture positive –11; 3-monthly for persistent culture positives –12; Culture reversion –13: Failure of MDR/RR-TB regimen –14; Recurrent case of second line treatment –15

Typ

e of

DR

TB

Pat

ient

RR

TB

/MD

RT

B/X

DR

T

B

DR

TB

Reg

ime

n #

Dat

e of

Tre

atm

ent i

nitia

tion

Culture and DST Results at initiation and during DR TB Treatment (Treatment months) TB/HIV Collaborative activities

Fin

al T

reat

men

t Out

com

e

Post treatment follow up

Rem

arks

0 3 4 5 6 7 9 12 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36

Dat

e of

Tes

t

PID

No

HIV

Sta

tus

Dat

e of

CP

T in

itiat

ion

Dat

e of

AR

T in

itiat

ion

6 m

12m

18m

24m

dd/m

m/y

y dd/m

m/y

y dd/m

m/y

y dd/m

m/y

y dd/m

m/y

y dd/m

m/y

y dd/m

m/y

y dd/m

m/y

y dd/m

m/y

y dd/m

m/y

y dd/m

m/y

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m/y

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m/y

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m/y

y dd/m

m/y

y dd/m

m/y

y dd/m

m/y

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m/y

y dd/m

m/y

y dd/m

m/y

y dd/m

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y dd/m

m/y

y dd/m

m/y

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m/y

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m/y

y dd/m

m/y

y dd/m

m/y

y dd/m

m/y

y dd/m

m/y

y dd/m

m/y

y Clin

ical

Clin

ical

Clin

ical

Clin

ical

Cul

ture

Cul

ture

Cul

ture

Cul

ture

Cul

ture

Cul

ture

Cul

ture

Cul

ture

Cul

ture

Cul

ture

Cul

ture

Cul

ture

Cul

ture

Cul

ture

Cul

ture

Cul

ture

Cul

ture

Cul

ture

Cul

ture

Cul

ture

Cul

ture

Cul

ture

Cul

ture

Cul

ture

Cul

ture

Cul

ture

Cul

ture

Cul

ture

Cul

ture

Cul

ture

Spu

tum

Spu

tum

Spu

tum

Spu

tum

# Cases put on: Regimen for H mono/poly resistant TB – 1; Regimen for MDR/RR TB – 2; Regimen for MDR/RR-TB + FQ/SLI resistance – 3; Regimen for XDR-TB – 4; Regimen with Bedaquiline for MDR-TB + FQ/SLI resistance – 5; Regimen with Bedaquiline for XDR-TB – 6; Regimen with Bedaquiline for failures of regimen for MDR-TB + FQ/SLI resistance – 7; Regimen with Bedaquiline for failures of regimen for XDR-TB – 8; Regimen with Bedaquiline for mixed pattern resistance – 9

1

Revised National Tuberculosis Control Programme – TB Notification Register Year ___________ PHI_________ Health Facility ID ___________

TB

not

ific

atio

n n

o.

(NIK

SHA

Y)

Name (in full)

Age

Sex

(M

/F/T

G)

Complete Address(including district /

state)

Pin

cod

e

Mob

ile

/L

and

lin

eN

um

ber

Aad

haa

r N

o.

Key

pop

ulat

ion

*

Typ

e of

pat

ien

t**

Sit

e (

P/E

P)

Cas

e D

efin

itio

n£ Microbiological confirmation test

resultsResults of

Other tests (X-

Ray/Histopatho/ FNAC/

Clinical/ /Other, specify)

HIV

Sta

tus±

Dia

bet

esS

tatu

s^

Dat

e of

sam

ple

sen

t fo

r D

ST

(N

O if

not

sen

t, N

A if

no

t app

lica

ble)

Res

ult

of

DS

T@ Status of

treatment***

Health facility for treatment (Details)

Dat

e of

init

iati

on o

f tr

eatm

ent

Date Lab Name

Lab no.

Test¥

Res

ult

s of

Tes

t#

………………… ………………………

………………… ………………………

………………… ………………………

………………… ………………………

………………… ………………………

………………… ………………………

………………… ………………………

*Key population1. Contact of TB/DRTB case, 2. Tobacco, 3. Prison inmates, 4. Miner, 5. Migrant, 6. Refugee, 7. Urban slum, 8. Health-care worker, 9. Other (specify)

** Type of patient (use complete words)New, Recurrent, Treatment after Failure, Treatment after Lost to Follow up, Other Previously Treated, Transferred in

£ Case DefinitionMicrobiologically Confirmed, Clinically Diagnosed

¥ Test ZN, FM, Culture, CBNAAT

# Result of testFor Smear result – Grades for smear positive (Scanty with no. of bacilli, +1, +2, +3), NEG for smear negativeFor GX result – MTB detected Rif Resistance, MTB detected Rif sensitive, MTB detected Rif Indeterminate, MTB not detected, Error, Invalid, No resultFor Culture result – Grades for culture positive, NEG for culture negative

± HIV StatusHIV status as reported before or during TB treatment R – Reactive, NR – Non-Reactive, U – Unknown.

^Diabetes Status D=Diabetes, N=NonDiabetes, U = Unknown

@ Sensitive= if sensitive to tested drugs, Name of drug if resistant to any – R= Rifampicin, H=Isoniazide, E=Ethambutol, Z=Pyrazinamide, Sm=Streptomycin Lx=Levofloxacin, Mx=Moxifloxacin, Km=Kanamycin, Cm=Capreomycin

***Status of treatment-1. Initiated on First line treatment in the same Health Facility2. Initiated on treatment outside Health Facility 3. Initiated on second line treatment 4. Treatment initiated outside RNTCP5. Incomplete/ incorrect address6. Died7. Migrated & untraceable8. Refuse for treatment9. Repeat diagnosis10. Patient already on treatment/ Follow up patient11. Wrong diagnosis12. Referred for treatment with pending feedback13. Other

2

Revised National Tuberculosis Control Programme – TB Notification Register Year ___________ PHI__________ Health Facility ID ___________

Typ

e of

reg

imen

(N

/ P

T /

Ou

tsid

e R

NT

CP

)

Wei

ght

at b

egin

nin

g of

tre

atm

ent

Dos

age

Fre

qu

ency

(D

aily

/ In

term

itte

nt) Follow-up smear examinations

Treatment Outcome#

If HIV-Reactive

Post treatment follow up

End of IP End of Treatment ExamAt 6 monthsDate______

At 12 months Date______

At 18 monthsDate______

At 24 monthsDate______

Treatment supporter details

Remarks

DateDMC Name

Smear result

Date of sample

collected for DST

Result of

DST@Date

DMC Name

Smear results

Date of sample collecte

d for DST

Resultof

DST@Outcome Date

CPT (y/n) date

ART (y/n) date

Sym

pto

ms

* CX

R

Sm

ear

Cu

ltu

re

Sym

pto

ms

CX

R

Sm

ear

Cu

ltu

re

Sym

pto

ms

CX

R

Sm

ear

Cu

ltu

re

Sym

pto

ms

CX

R

Sm

ear

Cu

ltu

re

Name Designation

# Treatment Outcome –Cured, Treatment Completed, Died, Lost to follow up, Failure, Not evaluated or Treatment change

± Additional treatments if patient HIV-ReactiveRequired only for patients known to be HIV Reactive. If provided by any source during TB treatment, enter “Y” and approximate date. If not provided / unknown, enter “N”.*Symptoms- Mention predominant system- Cough-C, Fever-F, Haemoptysis-H, Weight loss-W, Night Sweat - N Others-O, No symptoms - NS

Lab.

Ser

ial N

o. Date of collection

of first specimen

Name (in full)

Age

Sex

M/ F

/TG

Complete address (for diagnosis

patients) & Phone No.

Key Population1

Name and type of

referring health facility2

Reasons for Examination

Presumptive TB / RE /

Presumptive NTM

Predominant symptom3 & its duration4

History of >1 month

ATT (Yes/No)

Follow-up

Nikshay ID

Regimen New (N) / Previously

Treated(PT)

Month

Post Treatment follow up

month

1 Key population – 1. Contact of TB/DRTB case, 2. Tobacco, 3. Prison inmates, 4. Miner, 5. Migrant, 6. Refugee, 7. Urban slum, 8. Health-care worker, 9. Other (specify) 2 Name of referring health facility-PHI/DMC/TB/DTC/ICTC/ART/Medical College/DR-TB centre / Private/ Others, specify3Predominant symptoms: Cough-C, Fever-F, Haemoptysis-H, Weight loss-W, Night Sweat - N Others-O, No symptoms - NS4Duration of predominant symptoms should be recorded in days

TB Laboratory Register

Type of specimen

Visual appearance5 Results

Date of Result

HIV status (Reactive/

Non Reactive/ Unknown)

Diabetic status

(Diabetic/ Non

Diabetic/ Unknown)

Sample for DST

sent (Y/N) with date

DST result7 (write the drugs to which resistance is

demonstrated)

NIKSHAY ID (notification

no.)

Treatment initiation details

(TB No. & TU details) / Referral for

treatment

Signature Remarks8

a6 b6 a6 b6

5Visual appearance- mention M, B, or S., Mucopurulent, Blood stained or Saliva6a- stands for supervised spot sample, b- stands for early morning sample7 Sensitive= if sensitive to tested drugs, Name of drug if resistant to any – R= Rifampicin, H=Isoniazide, E=Ethambutol, Z=Pyrazinamide, SM=Streptomycin Lx=Levofloxacin, Mx (0.5) or (2) =Moxifloxacin, Km=Kanamycin, Cm=Capreomycin, Am=Amikacin, Eto=Ethionamide, Lzd=Linezolid, Cfz=Clofazimine8 Remarks column can include date of starting treatment, treatment regimen, TB no., referral details with date, remarks on un blinded rechecking, etc.

RNTCP Laboratory Register for culture, CBNAAT and drug susceptibility testing

S No

NIKSHAY ID

Patient’s full name(Address/contact

details)Age

Ge

nd

er

(M/F

/TG

)

Key Population1

Name and type (PHI / DMC / TU/ DTC /

ICTC / ART / Medical College / DR-TB Centre

/ Private Others, specify)

of referring health facility

Reason for testing Date

Ty

pe

(S

pu

tum

/oth

er-

sp

ec

ify

)

Sp

ec

imen

co

nd

itio

n #

(M

/B/S

/C)

C&

DS

T L

ab

Mic

ros

co

py

R

es

ult

Diagnosis/DST Follow up

Sp

ec

imen

co

llec

tio

n

Sp

ec

imen

sen

t to

lab

Sp

ec

imen

re

cei

pt

at

lab

ora

tory

New/ PT

@

Pre

dom

inan

t sy

mpt

om2

and

dura

tion3

PMDT TB No

Month of FU

@ Presumptive TB – 1; Private referral – 2; Presumptive NTM – 3;

@ Presumptive MDR TB, At diagnosis–4; Contact of MDR/RR TB – 5; Follow up Sm +ve at end IP – 6; private referral – 7; Discordance resolution – 8; Presumptive H mono/poly – 9; MDR/RR TB at diagnosis – 10; ≥ 4 months culture positive –11; 3-monthly for persistent culture positives –12; Culture reversion –13: Failure of MDR/RR-TB regimen –14; Recurrent case of second line treatment –

# M–Mucopurulent; B– Blood stained; S– Saliva; C– Contaminated

1 Key population – 1. Contact of TB/DRTB case, 2. Tobacco, 3. Prison inmates, 4. Miner, 5. Migrant, 6. Refugee, 7. Urban slum, 8. Health-care worker, 9. Other (specify) 2Predominant symptoms: Cough-C, Fever-F, Haemoptysis-H, Weight loss-W, Night Sweat - N Others-O, No symptoms - NS3Duration of predominant symptoms should be recorded in days

RNTCP Laboratory Register for Culture, CBNAAT and Drug Susceptibility Testing

Rapid DST ResultsCulture Results

Standard DST Results (R/S) Reporting of results

Te

st

pe

rfo

rme

d

(LP

A/C

BN

AA

T)

Da

te o

f re

ceip

t &

CD

L

NIK

SH

AY

ID

Va

lid

* (Y

/N)

TB

† (

Y/N

)

RIF

‡

(

R /

S /

I /

N A

)

INH

(in

hA

)(R

/S/N

A)

INH

(K

atG

)(R

/S/N

A)

Ty

pe

(L

J/L

C)

CD

L N

IKS

HA

Y I

D

Re

su

lts

§

Ty

pe

(L

J/L

C)

Da

te o

f re

ceip

t &

CD

L

NIK

SH

AY

ID

Rif

am

pic

in

Iso

nia

zid

(0

.1)

Iso

nia

zid

(0

.4)

Str

ep

tom

yci

n

Eth

am

bu

tol

Py

razi

nam

ide

Ka

na

my

cin

Ca

pre

om

yci

n

Am

ika

cin

Le

vo

flo

xa

cin

Mo

xif

lox

aci

n (

0.5

)

Mo

xif

lox

aci

n (

2.0

)

Eth

ion

am

ide

PA

S

Lin

ezo

lid

Clo

fazi

min

e

Oth

er

__

___

__

___

___

Oth

er

__

___

__

___

__

Oth

er

__

___

__

___

__

Da

te o

f re

po

rtin

g

cu

ltu

re r

esu

lt

Da

te o

f re

po

rtin

g D

ST

re

su

lt

Re

ma

rks

* Valid = Y if both Amplification Control (AC) band & Conjugate Control (CC) band present; if either are missing, record N, and record no additional LPA results for this specimen.

† TB = Y if M. tuberculosis (TUB) band on LPA strip confirming identity as M. Tb or MTB Detected in CBNAAT, N if no TUB band on LPA strip or MTB Not Detected in CBNAAT

‡ R = Resistant, S = Sensitive, I = Indeterminate, NA = no result, judged by no locus control band on LPA strip for rpo-B (RIF), or for inh-A or kat-G (INH) or for gyr-A or gyr-B for FLQ or eis for ETH, or rrs for SLI. In case of CBNAAT, specify for NA, i.e. Error, Invalid, No Result

§ Negative = no growth, Conta = contaminated, NTM = Non-Tuberculosis Mycobacteria/fast grower, 3+ = confluent growth, 2+ = >100 colonies, 1+ = 10–100 colonies; Sc# Scanty <10 . Positive culture results should only be reported after identity for M. tuberculosis is confirmed with PNB, Niacin, Catalase, Rapid Immunoassay, or other methods.