TB Public Health Clinic Forms

Reporting & Notification Forms

3140 New TB Suspect Referral revised 03/2015

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 

         Notification Form revised 05/2015

         Follow-up Form revised 11/2014

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,


DPH04/328HW Medication Information revised 12/2011

         EnglishBhutanese,BurmeseChinese, Farsi, KoreanNepali,


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

         English, BhutaneseBurmeseChineseFarsi, KoreanNepali,


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



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

         EnglishBhutanese, BurmeseChineseFarsi, KoreanNepali,


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



603.LTBI Consent and Treatment Plan for Latent Tuberculosis Infection (LTBI) with Directly Observed Therapy created 3/2015

Case Management/Clinic Forms

3121-R Tuberculosis Services revised 01/2016

3126 Contact Investigation Report revised 10/2014

3130 DOT Medication Sheet revised 02/2015

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 02/2015

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

3143 Bacteriologic Examinations Record revised 12/2011

Case Review Format revised 12/2011

12 point of Tuberculosis (TB) Patient Education revised 08/2015

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

Refusal of HIV Testing form revised 09/2013

TB Assessments

Tuberculosis (TB) Symptom Screen   (revised 02/2015)


Tuberculosis (TB) Risk Assessment

EnglishBosnian, SomaliSpanish, Vietnamese

Tuberculosis (TB) Risk Assessment Child Health Services EnglishSpanish



Page last updated 03/23/2016