Reporting Instructions for Civil Surgeons

What should be reported?

Civil surgeons are required to report tuberculosis (TB) screening outcomes that result in latent TB infection (LTBI) or active TB disease to the local health department (LHD) in which their patient resides. 

All reporting notifications to local TB programs should include: applicant’s name, contact information, IGRA results, chest x-ray report, and treatment results.

Visit the CTCA Directory to contact your local TB program for specific reporting or referral instructions.

Report or Refer? Category Definition Note
Report Latent TB Infection (LTBI)

Positive IGRA

Chest x-ray not suggestive of TB disease

No known HIV status

No signs or symptoms of active TB disease

Applicants who have written documentaiton of completing LTBI treatment prior to the civil surgeon examination should not need be reported.
Refer Applicants with HIV infection If the applicant has a known HIV infection, an IGRA and chest x-ray must be performed. Regardless of the results, the applicant must be referred to their LHD of residence for sputa collection.
Report and refer Active TB disease (suspected or confirmed)

Abnormal chest x-ray suggestive of TB disease, regardless of symptoms

Clinical signs or symptoms of suggestive TB disease

Extra pulmonary disease, regardless of chest x-ray results

Any confirmed or suspected case of active TB disease is required, by law, to be reported to the applicant’s LHD of residence within one business day.

How should LTBI be reported?

California civil surgeons should visit the CTCA Directory to contact their local TB program for specific reporting instructions, which may include reporting via CalREDIE Provider Portal or submission of a Confidential Morbidity Report (CMR).

For the CalREDIE Provider Portal system, registration and instructions can be found here:

1) General information on CalREDIE Provider Portal

CalREDIE Provider Portal Flyer (posted 02/2020)

2) CalREDIE Provider Portal account registration/authorization

Provider Portal Authorization Form (posted 02/2020)

3) Step-by-step and screenshots of reporting in CalREDIE

California LTBI Reporting Instructions (rev 10/2018)

How should suspected or active TB be reported and referred?

California civil surgeons should contact their local TB program for specific instructions to refer suspected or active TB disease.

Many LHDs prefer notification via phone, secure fax, or secure email, in addition to submission of a Confidential Morbidity Report (CMR).

Visit the CTCA Directory to contact your local TB program for specific reporting and referral instructions.

U.S. Citizenship and Immigration Services

Form I-693 – Report of Medical Examination and Vaccination Record

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