<p> BCG – Referral Professional Use Only</p><p>Forename: Family Name: Gender: DOB:</p><p>Address:</p><p>Tel no/mobile: GP:</p><p>Consent to a TEXT reminder? NHS no: Parent Signature required: Referred By: Refers Contact details: Referral date: Reason for referral: Criteria Details: please complete Infants and older children  Born in an area with a TB notification rate >40 (29 days – up to 1 years old) per 100,000 or  One or more parents or grandparents born in high-incidence country (list overleaf)  Family history of TB in previous 5 years.  Travelling to an area of high risk for 3 months (12 weeks) or longer, and living with the indigenous population. </p><p>Has the individual if younger than 1 year old, been visiting (and living with the indigenous population) for longer than 12 weeks in a high risk country? Yes / No Details: </p><p>Are there any known contra-indications to BCG that you are aware of? i.e. immunosuppressive disease, HIV, steroid therapy. Yes / No If yes, please list details and provide 2 letters of negative HIV result. </p><p>Refer to Chest Physician Contacts of people with active TB or for advice, contact: Sue Shippam, Clinical Nurse Manager-TB Services, 01932 723752 mob: 07976103305 PLEASE POST TO YOUR LOCAL CHILD HEALTH DEPARTMENT  Ewell: Carmela Tallo - Child Health, Ewell Court Clinic, Ewell Court Avenue, Epsom, KT19 0DZ. Tel: 0208 394 8150  Redhill: Mary Buick - Child Health Officer, St. Johns Court, 51 St. Johns Road, Redhill, RH1 6DS. Tel: 01737 214804  Woking: Tanya Newman - Child Health, Goldsworth Park Health Centre, Denton Way, Woking, GU21 3LQ. Tel: 01483 728201  Guildford: Tanya Newman Child Health, Goldsworth Park Health Centre, Denton Way, Woking, GU21 3LQ Tel: 01483 728201 </p><p>High Incidence Countries overleaf. Aug 2015</p><p>Page 1 BCG – Referral Professional Use Only High Incidence Countries – rate 40 & over per 100,000 population (WHO List 2013) Virgin Care updated Aug 2015 A G N U Afghanistan Gabon Namibia Uganda Algeria Gambia Nauru Ukraine Angola Georgia Nepal UR Tanzania Armenia Ghana Nicaragua Uzbekistan Azerbaijan Greenland Niger Nigeria B Guatemala Northern Mariana Islands V Bangladesh Guinea O Viet Nam Belarus Guinea-Bissau Vanuatu Guyana P W Benin Pakistan Bhutan H Palau X Bolivia Honduras Panama Bosnia Herzegovina Haiti Papua New Guinea Y Botswana I Paraguay Yemen Brazil India Peru Brunei Darussalam Indonesia Philippines Z Burkina Faso Iraq Zambia Burundi Q Zimbabwe J Qatar C Cambodia K R Cameroon Kazakhstan Republic of Korea Cape Verde Kenya Republic of Moldova Central African Republic Kiribati Romania Chad Kyrgyzstan Russian Federation China Rwanda China, Hong Kong SAR L China, Macao SAR Lao PDR S Latvia Sao Tome & Principe Côte d’Ivoire Lesotho Senegal Liberia Sierra Leone D Libya Singapore Djibouti Lithuania Solomon Islands Dominican Republic Somalia DPR Korea M South Africa DR Congo Madagascar Sri Lanka Malawi Sudan South E Malaysia Ecuador Maldives Swaziland Equatorial Guinea Mali Ethiopia Marshall Islands T Eritrea Micronesia Tajikistan Mongolia Thailand F Morocco Timor-Leste Fiji Mozambique Togo Myanmar Turkmenistan Mauritania Tuvalu Page2 </p>