Formato de seguimiento domiciliario afiliados notificados por Tuberculosis

Fecha de la visita (dd/mm/aa): _______________________________________________

Fecha de notificación(dd/mm/aa): ____________________________________________

Nombre y Apellidos Completos________________________________________________

Tipo documento: NV______ RC_____ TI ____ CC_____C. Extranjería_____ Pasaporte____
Menor sin Id. ____ Adulto sin Id. ____ N° de identificación: _________________________
Sexo____________________________ Régimen __________________________________
Edad: _______ grupo poblacional: Gestante_____ Fecha probable de parto____________
Indígena_______ Mujer en edad fértil (14 a 49 años) ________ Menor de 18 años______
Departamento de residencia: ______________ Municipio de residencia: ______________
Direccion__________________________________________________________________
Teléfono: _______________ Ocupación_________________________________________

Hallazgos
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 Acciones desarrolladas
Educación:_________________________________________________________________
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Demanda inducida: _________________________________________________________
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Observaciones:_____________________________________________________________
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Firma del afiliado o quien recibe la visita Firma del agente educativo
CC: