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["TB Indicator Data Reporting Form - 2018"]
["Name of Panel Site & Country: "]
["Date of submission:                                      "]
["Year data collected:  January - December 2018                        "]
[{"$nulls":4},"TB Indicators for Each Calendar Month (2018)"]
["Indicator","Jan.","Feb.","Mar.","Apr.","May","June","July","Aug.","Sept.","Oct.","Nov.","Dec.","TOTAL"]
["1. Number of Applicants Examined"]
["1a. Total number of applicants examined\n      (ALL APPLICANTS OF ANY AGE: 1b + 1c + 1d)",0,0,0,0,0,0,0,0,0,0,0,0,0]
[" 1b. Number of Applicants ≥ 15 years old examined",0,0,0,0,0,0,0,0,0,0,0,0,0]
[" 1c. Number of applicants 2-14 years old examined",0,0,0,0,0,0,0,0,0,0,0,0,0]
[" 1d. Number of applicants < 2 years old examined",0,0,0,0,0,0,0,0,0,0,0,0,0]
["2. Number with Sputum Required (TB Suspects)"]
["2a. Abnormal CXR Suggestive of TB",0,0,0,0,0,0,0,0,0,0,0,0,0]
["2b. Normal CXR with signs/symptoms TB (do NOT include positive TST/IGRA here)",0,0,0,0,0,0,0,0,0,0,0,0,0]
["2c. Known HIV infection (w/Normal CXR & no Signs TB)",0,0,0,0,0,0,0,0,0,0,0,0,0]
["2d. TOTAL",0,0,0,0,0,0,0,0,0,0,0,0,0]
["2e. TOTAL With Sputum Submitted (i.e. number of applicants who returned to complete TB testing requirements) ",0,0,0,0,0,0,0,0,0,0,0,0,0]
["3. Non TB Mycobacteria"]
["3a. Smear+ /NTM+",0,0,0,0,0,0,0,0,0,0,0,0,0]
["3b. Smear- /NTM+",0,0,0,0,0,0,0,0,0,0,0,0,0]
["3c. TOTAL",0,0,0,0,0,0,0,0,0,0,0,0,0]
["4. Extrapulmonary TB Cases"]
["4a. Extrapulmonary TB Cases",0,0,0,0,0,0,0,0,0,0,0,0,0]
["5. Pulmonary CLASS A TB Cases ONLY\n","***IMPORTANT***  ONLY \"Class A\" TB cases undergoing TB treatment should be reported in Section 5; DO NOT include B1 TB cases with smear- / culture- results here "]
[" 5a. Smear + / MTB Culture + ",0,0,0,0,0,0,0,0,0,0,0,0,0]
[" 5b. Smear + / MTB Culture -",0,0,0,0,0,0,0,0,0,0,0,0,0]
[" 5c. Smear - / MTB Culture +",0,0,0,0,0,0,0,0,0,0,0,0,0]
[" 5d. Smear - / MTB Culture - (do NOT include B1s here)",0,0,0,0,0,0,0,0,0,0,0,0,0]
[" 5e. Smear+ /Culture Contamination",0,0,0,0,0,0,0,0,0,0,0,0,0]
[" 5f. Smear- /Culture Contamination",0,0,0,0,0,0,0,0,0,0,0,0,0]
[" 5g. TOTAL",0,0,0,0,0,0,0,0,0,0,0,0,0]
["6. Drug Susceptibility Testing (DST) Results","**NOTE:  DST results are required for all culutre positive isolates per CDC's TB Technical Instructions\nTotal in Row 6i should equal Row 5a + 5c"]
[" 6a. Pansusceptible",0,0,0,0,0,0,0,0,0,0,0,0,0]
[" 6b. INH Monoresistance",0,0,0,0,0,0,0,0,0,0,0,0,0]
[" 6c. RIF Monoresistance",0,0,0,0,0,0,0,0,0,0,0,0,0]
[" 6d. MDR TB",0,0,0,0,0,0,0,0,0,0,0,0,0]
[" 6e. XDR TB",0,0,0,0,0,0,0,0,0,0,0,0,0]
[" 6f. Poly-resistance, not MDR or XDR TB",0,0,0,0,0,0,0,0,0,0,0,0,0]
[" 6g. Monoresistant to drug other than INH/RIF",0,0,0,0,0,0,0,0,0,0,0,0,0]
[" 6h. Unable to do DST due to NTM contamination (i.e., there was NTM overgrowth so that performing DST was not possible)",0,0,0,0,0,0,0,0,0,0,0,0,0]
[" 6i. TOTAL",0,0,0,0,0,0,0,0,0,0,0,0,0]
["7. Pulmonary TB Treatment"]
["7a. DOT completed or in-progress at DGMQ-approved site",0,0,0,0,0,0,0,0,0,0,0,0,0]
["7b. Declined DOT at DGMQ-approved site",0,0,0,0,0,0,0,0,0,0,0,0,0]
["7c. TOTAL",0,0,0,0,0,0,0,0,0,0,0,0,0]
["NOTES  (please include any information here that you think may be helpful for CDC to have to interpret the information entered above or information about unique situations): "]
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["Public reporting burden of this collection of information is estimated to average 3 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74,  Atlanta, Georgia 30333; ATTN:  PRA (0920-1102)"]

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["Last name","First name","Rank","Organization","e-mail","Phone number","Location","Notes","Specific activity or interest","Continue membership - yes/no","Preferred time (EDT) for calls","emailed for removal",null,"joined"]