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Annexure 12 A
Line-List Of Persons Referred From ICTC To RNTCP
REPORTING MONTH: YEAR NAME OF ICTC: NAMEOF DISTRICT:
TO BE COMPLETED BY ICTC COUNSELLOR
TO BE COMPLETED BY the STS
1
2
3
4
5
6
7
8
9
10
11
12
13
14
Sr.
No.
PID
NO
Complete
Name
&
Complete
Address
Age
Sex
HIV status
(R / NR /
Unknown)
Date of
referral
to
RNTCP
Name of
facility
referred
to
Is patient
diagnosed
as TB –Yes
or No
If diagnosed as
TB, specify type
of TB and basis
of diagnosis
Is patient
initiated
on
RNTCP
treatment
Date of
Starting
Treatment
TB
No.
Remarks
Sign of Counsellor Sign of MO- ICTC
Date of completion:
Name of the TU:
Signature of STS Signature of DTO/CTO/MO-TU
Date of Completion:
–
–
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