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TB Public Health Clinic Forms

Reporting & Notification Forms

3140 New TB Suspect Referral revised 12/2011

3141 Initial Report on Patient with TB revised 12/2011

3142 Follow-up Report on Patient with TB revised 12/2011

NTCA 3-2002 Interjurisdictional Tuberculosis Notification 

         Instructions revised 03/2002

         Notification Form revised 03/2002

         Follow-up Form revised 05/2002

CDC72.9A Report of Verified Case of Tuberculosis (RVCT)  revised 09/2008

Legal Forms

3144 Active Tuberculosis (TB) Treatment Plan revised 12/2011

         EnglishBhutaneseBurmeseChinese, Farsi, KoreanNepali,

         SpanishVietnamese

DPH04/328HW Medication Information revised 12/2011

         EnglishBhutanese,BurmeseChinese, Farsi, KoreanNepali,

         SpanishVietnamese

3575 Refusal of Care Form - TB Program revised 12/2011

         English, BhutaneseBurmeseChineseFarsi, KoreanNepali,

         SpanishVietnamese

3609.LTBI LTBI Consent and Treatment Plan - Latent TB Infection revised 12/2011

         EnglishBhutanese,BurmeseChineseFarsiKoreanNepali,

         SpanishVietnamese

3609.TB Consent to Treatment - Active TB Case/Suspect revised 12/2011

         EnglishBhutanese, BurmeseChineseFarsi, KoreanNepali,

         SpanishVietnamese

603.DOT Directly Observed Therapy (DOT) Agreement for TB Treatment revised 12/2011

         EnglishBhutanese,BurmeseChineseFarsiKoreanNepali,

         SpanishVietnamese

Case Management/Clinic Forms

3121-R Tuberculosis Services revised 08/2014

3126 Contact Investigation Report revised 12/2011

3130 DOT Medication Sheet revised 12/2011

INH-RPT Isoniazid/Rifapentine Reporting & DOT revised 10/2012

        Instructions for INH/RPT Reporting form revised 10/2012

3135 Tuberculosis Flowsheet revised 07/2014

TB/HIV TB/HIV Flowsheet revised 12/2011

DPH04/324 MDR-TB Flowsheet revised 12/2011

2nd Line Second Line Therapy Authorization Form revised 12/2011

HAIN HAIN Rapid TB Diagnostic & Resistance Submission Form revised 12/2011

3143 Bacteriologic Examinations Record revised 12/2011

3412-HD Georgia Public Health Laboratory - TB Submission Form revised 12/2011

Case Review Format revised 12/2011

12 point of Tuberculosis (TB) Patient Education revised 04/2012

Tuberculosis Education Record revised 04/2012

Scaled Goal Matrix Tool

Case Management Timeline

Client Referral Form revised 10/2011

TB Worksheet - Class B1/B2, aliens

TB Assessments

Tuberculosis (TB) Symptom Screen                                                               EnglishBosnian,SomaliSpanishVietnamese

Tuberculosis (TB) Risk Assessment

EnglishBosnian, SomaliSpanish, Vietnamese

Tuberculosis (TB) Risk Assessment Child Health Services EnglishSpanish