ASSESSMENT OF THE TB IN PRISON PROGRAM

QUESTIONNAIRE
Note:
This questionnaire was developed as a guide or tool for TB program coordinators and
managers in gathering important and relevant baseline data in jails or prison that plans to
implement or establish TB in Prison Program. Once filled up, the tool will provide data and
information on the status of TB program implementation in jail/prison; and weakness and
gaps in the program and the facility.

INFORMATION
Prison/Jail: _________________________________
Address:

_________________________________

Respondent & Position: ____________________

______________________________________________________________
Date accomplished:

____________________________

I. PRISON/JAIL PROFILE
1.1 Type of prison:
Mun.__

National_

Regional_

Provincial__

City _

National-supported___ LGU-support
I.2Capacity:
pop.: __

Ofcial inmate pop.: __

Actual

inmate

I.3 Manpower complement:

I.3.1 Health:
Doctor___ Nurse __
MedTech/Microscopist___
Others___ Please
Specify____________________________
I.3.2 Non-health: ________________
Warden__

Jail Guards___

Admin staff___

Others___

Please specify______________________________

I.4Availability of the health facility and services: (please check)

I.4.1 Has a general clinic:
I.4.1.1

YES ___

NO ___

If NO, where do you refer sick inmates?

I.4.1.1.1 For consultation:

facility ___

Nearest

govt.

health

Private health facility ___

IMPACT

ASSESSMENT OF THE TB IN PRISON PROGRAM

QUESTIONNAIRE
I.4.1.1.2 For laboratory work-up: Nearest Govt. health
facility __
Private health facility ___
I.4.2 Is
II.

transportation service
YES___
NO ____

provided

to

referral

facility:

MANAGEMENT OF INMATES WITH TUBERCULOSIS

II.1

Do you follow the DOTS protocol

YES ___

NO ___

II.1.1
If YES, when did the facility started implementing DOTS
(month/year)________
II.1.1.1

Jail staff were oriented on TB DOTS program YES

NO___

II.1.1.2

Jail team was trained on TB DOTS program

NO___

II.1.2
II.2

If NO, are you aware of the DOTS protocol

NO___

YES __
YES __

Does the jail/prison manages its own inmates suspected with TB

YES __NO___
II.2.1 If NO, where do you refer TBS inmates?
DOTS facility:
RHU___
specify______________

Hospital___

Non-DOTS facility: Hospital___ Clinic___

specify_____________
II.3

II.4

Clinic___

Others,

Others,

Who are the treatment partners assigned to the TB patients?

II.3.1

Health staff:
NO__

YES _ , pls. specify who ________

II.3.2

Jail/Prison staff (non-health): YES

______ NO__

II.3.3

Inmates:

YES

NO

_______

II.3.4

Others:

YES

NO

_______

Are anti-TB drugs available: YES

II.4.1

, pls. specify who

NO ____

What is the source of the Anti-TB drugs?

II.4.1.1

Rural Health Unit

_____________

II.4.1.2

Procured by the jail/prison

II.4.1.3

Other sources, specify:

_____________

IMPACT

ASSESSMENT OF THE TB IN PRISON PROGRAM

QUESTIONNAIRE
_____________________________
II.4.2
Have there been periods of stockout of drugs? Yes:
_____ No.: ______
III.

STATUS OF SICKNESS AND DEATHS DUE TO TB IN

JAIL/PRISON
III.1 TB sickness among inmates (Interview medical/jail staff, check
any records) _____

Year

Inmat
e Pop.

Total No.
of TB
Cases
Referred

No.
Diagnosed
w/
susceptible
TB

No.
No.
No.
No. of TB
Diagnose Diagnose Diagnose
cases
d w/ DR
d w/
d w/ XDR
diagnosed
TB
MDR TB
TB
HIV positive

III.2 TB sickness among jail/prison staff (Ask medical/jail staff, check

any records) _____
Year

Total
Jail
Staff

Total No.
of TB
Cases
Referred

No.
Diagnosed
w/
susceptible
TB

No.
No.
No.
No. of TB
Diagnose Diagnose Diagnose
cases
d w/ DR
d w/
d w/ XDR
diagnosed
TB
MDR TB
TB
HIV positive

III.3 TB deaths among inmates in the current year (no):

_________
III.4 TB deaths among jail/prison staff in the current year (no.):
_________
IV.

TB PROGRAM IMPLEMENTATION

Please indicate your agreement or disagreement with the items below by

checking the appropriate column.
IV.1 Administration
IMPACT

ASSESSMENT OF THE TB IN PRISON PROGRAM

QUESTIONNAIRE
No.

Item

IV.1.
1
IV.1.
2
IV.1.
3.
IV.1.
4

There is a signed Memorandum of Understanding

(MOU) with the LGU.
A jail/prison DOTS Team has been organized.

Yes

No

Yes

No

The jail/prison DOTS team meets at least once a

month.
All members of the jail/prison DOTS Team have
been oriented or trained on DOTS.

IV.2 Management of TB Patients

No.

Item

IV.2.1 On the average, results of sputum microscopy are

available within five working days.
IV.2.2 On the average, all inmates diagnosed as sputum
smear- positive are able to start treatment within
24 hours. If no, how many days? _________________
IV.2.3 All newly committed inmates (including those
transferred from other jails) are screened.
IV.2.4 The jail uses a screening checklist.
IV.2.5 A cough surveillance record is used to identify
inmates who are TB symptomatic.
IV.2.6 A trained TB Health Aide is assigned to each cell
to identify inmates who are TB symptomatic.
IV.2.7 All treatment partners are trained on DOTS.
IV.2.8 Before release, all inmates undergo the same
screening procedure described for newly
committed inmates.
IV.2.9 A comprehensive plan for continuing treatment
(where to be referred, schedule of follow-up, etc.)
is discussed with inmates who have not
completed treatment but are scheduled for
release.
IV.2.1 Inmates who are on treatment but scheduled for
0
release are properly endorsed to the receiving
DOTS facility for continuation of treatment using
the NTP Referral Form.
IV.3 Infection Control
No.
IV.3.

Item

Yes

No

A temporary holding area has been designated

IMPACT

ASSESSMENT OF THE TB IN PRISON PROGRAM

QUESTIONNAIRE
No.
1
IV.3.
2
IV.3.
3
IV.3.
4
IV.3.
5
IV.3.
6
IV.3.
7
IV.3.
8

Item

Yes

No

for smearpositive patients.

Inmates who are in the holding area undergo
DSSM after 2 weeks.
Smear-positive patients remain in the holding
area until the inmate has converted to smear
negative.
Smear-positive patients who are in the holding
area wear face masks.
TB symptomatics who have not been diagnosed
as sputum-positive wear face masks.
A sputum collection area has been designated.
The sputum collection area is in a well-ventilated
area (free flowing air away from the trafc)
outside the cell.
Infection control measures are included in the
training of DOTS team members and other jail
staff.

IV.4 Environmental Control Measures

No.
IV.4.
1

IV.4.
2

Item

Yes

No

The following environmental control measures are

applied to all cells, clinics, examination area,
separation or holding areas:
IV.4.1. Open windows
1
IV.4.1. Directional airflow
2
IV.4.1. Outdoor waiting area
3
IV.4.1. Collection of sputum outdoors, away from
4
other patients, visitors, and waiting area
IV.4.1. Exhaust fan, blowing potentially
5
contaminated air to the outside, when
resources permit
The point person regularly checks on the
implementation of these environmental control
measures.

IV.5 Health Promotion

IMPACT

ASSESSMENT OF THE TB IN PRISON PROGRAM

QUESTIONNAIRE
No.

Item

IV.5.
1
IV.5.
2

The jail/prison conducts health promotion

activities.
Target of health promotion activities are:

IV.5.
3

IV.6
No.
IV.6.
1
IV.6.
2
IV.6.
3
IV.6.
4
IV.6.
5

Yes

No

Yes

No

IV.5.2. Inmates
1
IV.5.2. Visitors of inmates (families and others)
2
IV.5.2. Jail Staff
3
IV.5.2. Others
4
Other health information topics included during
TB orientation of inmates were/are:
IV.5.3. Understand the importance of correct way
1
of collecting sputum for microscopy &
other lab. tests
IV.5.3. Importance of treatment using DOT and
2
significance of sputum follow-ups
IV.5.3. Simple measures to reduce the risk of
3
transmitting TB (e.g., cough manners,
spitting manners)
IV.5.3. How to obtain treatment should
4
immediate transfer or release occurs
without warning to the DOTS team
Program Management
Item
The jail/prison maintains an NTP Register.
All TB patients (inmates) have updated treatment
cards.
The jail/prison submits quarterly reports to the
PHO/CHO or CHD.
The LGU and CHD NTP staff conduct quarterly
supervision visits to the jail/prison.
The jail/prison team regularly analyzes data from
quarterly reports using standard program
indicators, and provide feedback of findings with
corresponding recommendations to the staff or
authorities concerned.
IMPACT

ASSESSMENT OF THE TB IN PRISON PROGRAM

QUESTIONNAIRE
IV.6.
6
V.

The jail/prison team plans and evaluates its TB

program implementation at least once a year.

TB Program Performance, 20___- 20____

Indicators

20____
No.
%

20____
No.
%

Current Year
No.
%

Population (Jail/Prison)
Presumptive TB identified
Presumptive TB examined
Laboratory exam:
No. with 2 sputum exams
No. with GX exam
No. bacteriologically
confirmed by:
DSSM
GX
Case Notification
No. New Bacteriologically
Confirmed Cases (BC)
No. Relapse
No. Treatment After Failures
(TAF)
No. Treatment After Lost To
Ff-Up (TALF)
No. New Clinically
Diagnosed Cases (CD)
No. Previous Treatment
Outcome Unknown (PTOU)
No. Extra-Pulmonary TB
(EPTB), New
Total Re-Treatment Cases
Total BC PTB
Total CD PTB
Total PTB
Total TB cases
Proportion of BC PTB
CNR (NSP) per 100K

%
IMPACT

ASSESSMENT OF THE TB IN PRISON PROGRAM

QUESTIONNAIRE
Indicators
CDR (NSP)
CNR (All Forms) per 100K
CDR (All Forms)
Treatment Outcome
(NSP)

20____
No.
%
%

20____
No.
%
%

Current Year
No.
%
%

2010

2011
%

No. entered to treatment

%
%

Converted
Cured
Treatment completed
Treatment Success Rate
Died
Failed
Lost to ff-up
Not evaluated
Total

Pulmonary Tuberculosis
Bacteriologically Confirmed Cases
New
Relapse
Others
M

Tota
l

Clinically
diagnosed
Cases
M
F

New
ExtraPulmonary
TB
M
F

Total

Tota
l

IMPACT

ASSESSMENT OF THE TB IN PRISON PROGRAM

QUESTIONNAIRE

[Revised as of 30 March 2016 by PFM]

IMPACT