Module 5: Quarterly Reporting

Quarterly Report on All TB Cases

(Source of Data-TB Register)

Name of CHD: Patient Registered duting the

_________Quarter of Year____________
Name of PHO/CHO: Date Submitted
Name of DOTS Facility: Prepared by:_____________________________
Name and designation

A. All TB cases registered during the quarter age-group:

0-4 YEARS OLD
Type New Relapse Trans-in RAD Treatment Other Other New EPTB
of S(+) Failure POSITIVE NEGATIVE Smear
Patient Negative
(1) (2) (3) (4) (5) (6) (6)- (7) (8)
M F M F M F M F M F M F M F M F M F
Public
Private
Sub-
Total
5-9 YEARS OLD
Public
Private
Sub-
Total
10-14 YEARS OLD
Public
Private
Sub-
Total
15 YEARS OLD AND ABOVE
Public
Private
Sub-
Total
TOTAL