Revised Technical & operational Guidelines for TB

Annexure 12B

ICTC TB-HIV monthly report

REPORTING MONTH: _______________

YEAR __________________

NAME OF ICTC:_____________________

DISTRICT:_______________

I. TOTAL NUMBER OF GENERAL CLIENTS ATTENDING ICTC:

a) Total no. of clients who attended ICTC in the month

(excluding PPTCT clients)

II.REFERRAL OF PRESUMPTIVE TUBERCULOSIS CASES FROM

ICTC TO RNTCP

HIV

positive

HIV

Negative

a) No. of persons presumptive to have TB referred to RNTCP

diagnostic services

b) Of the referred presumptive TB patients, No. diagnosed as

having:

(i) Pulmonary TB (Microbiologically confirmed)

(ii) Pulmonary TB (Clinically diagnosed)

(iii) Extra-Pulmonary TB (Microbiologically confirmed)

(iv) Extra Pulmonary (Clinically diagnosed)

c) Out of above (b), diagnosed TB patients, number receiving

RNTCP treatment

Signature of Medical Officer – In charge ICTC

Name of Medical Officer In-charge ICTC

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