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227
FORMS
FORM 02
DR-TB Control Programme
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Month 15
Month 16
Month 17
Month 18
Month 19
Month 20
Month 21
 Month 22
Month 23
Month 24
Month 25
Month 26
Month 27
Month 28
Month 29
Month 30
Month 31
Month 32
Month 33
Month 34
   S 
  C 
S   C 
  C 
   C 
S   C 
S   C 
   C 
  C 
S   C 
  C 
C   S 
  C 
S   C
 S 
   C    S 
  C 
   S 
C   S 
   C 
S   C
d/m/y
d/m/y
d/m/y
d/m/y
d/m/y
d/m/y
d/m/y
d/m/y
d/m/y
d/m/y
d/m/y
d/m/y
d/m/y
d/m/y
d/m/y
d/m/y
d/m/y
d/m/y
d/m/y
d/m/y
Smear (S) and culture (C) results during treatment
(if more than one smear or culture done in a month, enter the most recent positive result)
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228
GUIDELINES FOR THE PROGRAMMATIC MANAGEMENT OF DRUG-RESISTANT TUBERCULOSIS
HPF = high-power field
FORM 02
DR-TB Control Programme
Outcome
Cured
Completed
Failed
Died
Defaulted
Transferred out
Date outcome given
HIv testing
Testing done
(y/N/unknown)
Date
of test
Result
ART y/N
Start date
CPT y/N
Start date
Comments
TB/hIv activities
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No growth reported
0
Fewer than 10 colonies
Report number
of colonies
10–100 colonies
+
More than 100 colonies
++
Innumerable or confluent growth
+++
notation method for recording cultures
notation method for recording smears
(for non-centrifuged specimens)
No. AFB
0
1–9 AFB per 100 HPF
Scanty (and report
number of AFB)
10–99 AFB per 100 HPF
+
1–10 AFB per HPF
++
>10 AFB per HPF
+++
Drug abbreviations
First-line drugs
H = Isoniazid
R = Rifampicin
E = Ethambutol
Z = Pyrazinamide
S = Streptomycin
(Th = Thioacetazone)
Second-line drugs
Am = Amikacin
km = kanamycin
Cm = Capreomycin
Ofx = Ofloxacin
Lfx = Levofloxacin
Mfx = Moxifloxacin
Pto = Protionamide
Eto = Ethionamide
Cs = Cycloserine
PAS = P-aminosalicylic acid
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229
FORMS
FORM 03
DR-TB Control Programme
Request for sputum examination (to be completed by treatment centre)
Date taken
Laboratory
S
H
R
E
Z
km Am
Cm Ofx
Other
Other
specimen no.
1
2
RESULTS (to be completed in laboratory)
Smear results
Culture results
DST results
Treatment unit
Date
Patient name:
Age: 
Date of birth:
Sex (mark one)  M
 F
Address (in full)
Reason for examination (mark one):  diagnosis  follow-up examination
Test request (mark any that are needed):  smear  culture  drug-susceptibility testing
Signature of person requesting examination:
*visual appearance of sputum (blood-stained, mucopurulent, saliva)
No. AFB
0
1–9 AFB per 100 HPF 
Scanty (and report
number of AFB)
10–99 AFB per 100 HPF
+
1–10 AFB per HPF 
++
>10 AFB per HPF 
+++
Result (mark one)
neg.
1–9
+
++
+++
Date collected
Specimen
Laboratory
Appearance*
specimen no.
1
2
3
Date
Examined by (signature)
Date
Examined by (signature)
Date
Examined by (signature)
The completed form (with results) should be sent promptly to the treatment unit
R = resistant
S = susceptible
C = contaminated
No growth reported
0
Fewer than 10 colonies
Report number
of colonies
10–100 colonies
+
More than 100 colonies
++
Innumerable or confluent growth
+++
Date collected
Specimen
Laboratory
Result (mark one)
Contaminated
specimen no.
neg.
1–9
+
++
+++
1
2
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230
GUIDELINES FOR THE PROGRAMMATIC MANAGEMENT OF DRUG-RESISTANT TUBERCULOSIS
Laboratory Register for culture and DST
FORM 04
DR-TB Control Programme
Date
specimen
received
Laboratory
serial
number
Referring health facility
Patient name
Date of
birth
Type of
specimen
received
Patient address if new
Sex
M/F
Date
specimen
collected
Date
specimen
inoculated
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231
FORMS
Laboratory Register for culture and DST
FORM 04
DR-TB Control Programme
No growth reported
0
Fewer than 10 colonies
Report number of colonies
10–100 colonies
+
More than 100 colonies
++
Innumerable or confluent growth
+++
Signature
*
New patients or patients starting a re-treatment regimen.
**
Patient on TB treatment, indicate months of treatment at which follow-up examination is performed.
***Outcome of culture reported as follows:
Reason for examination
Diagnosis*
Follow-up**
Result of culture***
Result of confirmatory
test for M. tuberculosis
(positive or negative)
Culture sent
for DST
(yes or No)
Name of person
reporting DST results
Comments
Date results
reported
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232
GUIDELINES FOR THE PROGRAMMATIC MANAGEMENT OF DRUG-RESISTANT TUBERCULOSIS
Laboratory Register for culture and DST
km 
Cm 
Fq 
Other 
Other Other 
DST Results 
Name of person  
Signature 
Comments 
reporting DST results
Report DST results as s = susceptible, r = resistant, c = contaminated
FORM 04
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233
FORMS
Quarterly report on MDR-TB detection and Category Iv treatment start
Name of area ....................................................................................... 
Name of area coordinator .................................................................................................
Patients identified during ................. quarter of year ............................ 
Date ............................
1. number of patients detected with MDR-TB/xDR-TB in the lab (by date of result of MDR-TB/xDR-TB in labortory register) during the quarter:
MDR-TB 
xDR-TB 
2. number of MDR-TB patients who started Category Iv treatment during the quarter
New case 
Previously treated with first-line drugs 
Previously treated with second-line drugs
Confirmed cases
Suspected cases
1st quarter: 1st January–31 March
2nd quarter: 1er April–30 June
3rd quarter: 1er July–30 September 
4th quarter: 1er October–31 December 
Signature .......................................................................................
FORM 05
234
GUIDELINES FOR THE PROGRAMMATIC MANAGEMENT OF DRUG-RESISTANT TUBERCULOSIS
FORM 06
Six month interim outcome assessment of confirmed MDR-TB cases
(to be filled out 9 months after treatment start)
Name of Unit:
Date filled in:
Quarter treatment was started:
Date of the report: 
Number 
Bacteriological results at 5 and 6 months of treatment 
No longer on treatment
started on 
treatment 
Negative 
Positive 
Culture and smear unknown 
Died 
Defaulted 
Transferred
(all smears and cultures negative  
(any smear or culture  
(Consider unknown if a culture 
out
during month 5 and 6, and  
is positive during 
or smear results is not done
at least a smear and culture  
month 5 and 6) 
for either month 5 or 6)
done each month)
235
FORMS
Annual report of treatment result of confirmed MDR-TB patients  
starting Category Iv treatment
(to be filled in 24 and 36 months past the closing date of year of treatment)
year of treatment start:
Patient group 
Cured 
Treatment 
Failed 
Defaulted 
Died 
Transferred 
Still on 
Total 
completed 
out 
treatment
New
Previously treated with 
first-line drugs only
Previously treated with both 
first- and second-line drugs
Total
FORM 07
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