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Form 6a.

DRUG SUSCEPTIBLE TB REGISTER

Date of Registration

TB Case No. Name Date of Birth A

G
E

E
X

Address

Source of Patient

P/EP

Bacteriological Status

Anatomical Site

Registration Group Transfer - in Tx. Regimen


Public Health Center

/MD
unity

Comm
New

Relapse

TALF TAF

PTOU Other

Other Public Health Facility

Private Facility

Form 6a. DRUG SUSCEPTIBLE TB REGISTER


Source of Patient
Date of
Registrati
on

TB
Case
No.

Nam
e

Date
of
Birth

A
G
E

S
E
X

Addre
ss

Publi
c
Healt
h
Cent
er

Othe
r
Publi
c
Healt
h
Facili
ty

Priva
te
Facili
ty
/MD

Com
m
unity

Anat
omic
al
Site
P/EP

Bact
eriol
ogic
al
Stat
us

Tran
sfer
- in

Registration Group

New

Rel
aps
e

TAL
F

TAF

PTO
U

Othe
r

Tx.
Regi
men