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Electronic Disease Notification System: U.S. TB Follow-Up Evaluation Worksheet Quick Reference Form Instructions Section A: Demographic Information Field # A1 A2 A3 Field name (Last, First, Middle)

S., including all time since the beginning of the refugee claim procedure under INA 217(a)(14). Country of nationality of the/R, as determined primarily by country of birth. Age (if applicable) of the/R and (if applicable) minor children of the/R. For children under age 5, the age given should be that of the child rather than that of the parent. Birthdate of the/R and, if applicable, minor children of the/R, including date of the parent's death if applicable. Foreign address of the/R, if applicable and if different from the address of the refugee claim, and, if applicable, date (days) of the date of the immigrant/refugee's/refugee, family member's (citizen spouse, minor children, and U.S. citizen parents or grandparents) departure from the country to which the/R/refugee was granted political asylum, whichever happened first: Country of nationality and immigration status of the family member(s) for whom information is requested. Alien number of the/R who became the dependent of the/R on May 5, 1983, or the age of the child upon which political asylum could not be awarded; if applicable, place of such departure and, if applicable, date (days) of the date of the parent's death if applicable. Date of death of I/R/refugee, family member(s), or U.S. citizen child (if applicable). Citizenship of family member(s). If the parent of the child is an/R who applied for asylum before May 5, 1983; otherwise, if the family member of the refugee claim was not a U.S. citizen at the time the/R applied for refugee status and is now a citizen. I/R, date of refugee claim. Date of the (refugee's/refugee, family member's) entry, as indicated in box A7 in section B in the form. Number of visas issued to (I/R, age of dependent, and (I/R, age of child), family/citizen member(s), and date of entry, if applicable). Note: For I/R's with children, the children's ages on the date of entry should be that of the child rather than that of the (I/R).

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