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TB Public Health Clinic Forms

 

Form Number

Form Description

Rev Date

Reporting & Notification

3140

New TB Suspect Referral

12/2011

3141

Initial Report on Patient with TB

12/2011

3142

Follow-up Report on Patient with TB 

12/2011

NTCA 3-2002

Interjurisdictional Tuberculosis Notification
Instructions 
Notification Form 
Follow-up Form


03/2002
03/2002
05/2002

CDC72.9A

Report of Verified Case of Tuberculosis (RVCT) – print pp. 1-3
Follow-up Report 1 – print p. 4
Follow-up Report 2 –  print pp.5-6

09/2008

Legal

3144

Active Tuberculosis (TB) Treatment Plan [EnglishBhutaneseBurmeseChinese,Farsi
KoreanNepaliSpanishVietnamese]

12/2011

DPH04/328HW

Medication Information [EnglishBhutanese,BurmeseChinese, Farsi
KoreanNepali,SpanishVietnamese

12/2011

3575

Refusal of Care Form - TB Program [English,BhutaneseBurmese
ChineseFarsi, KoreanNepaliSpanishVietnamese

12/2011

3609.LTBI

Consent and Treatment Plan – Latent TB Infection (LTBI) [EnglishBhutanese,BurmeseChineseFarsi
KoreanNepali,SpanishVietnamese

12/2011

3609.TB

Consent to Treatment – Active TB Case/Suspect [EnglishBhutanese,BurmeseChineseFarsi
KoreanNepali,SpanishVietnamese

12/2011

603.DOT

Directly Observed Therapy (DOT) Agreement for TB Treatment [EnglishBhutanese,BurmeseChineseFarsi
KoreanNepali,SpanishVietnamese

12/2011

Case Management/Clinic

3121-R

Tuberculosis Services

12/2011

3126

Contact Investigation Report

12/2011

3130

DOT Medication Sheet

12/2011

INH-RPT

Isoniazid/Rifapentine Reporting & DOT

10/2012

INST

Instructions for INH/RPT Reporting form

10/2012

3135

Tuberculosis Flowsheet

12/2011

TB/HIV

TB/HIV Flowsheet

12/2011

DPH 04/324

MDR-TB Flowsheet

12/2011

2nd Line

Second Line Therapy Authorization Form

12/2011

HAIN

HAIN Rapid TB Diagnostic & Resistance Submission Form

12/2011

3143

Bacteriologic Examinations Record

12/2011

3412-HD

Georgia Public Health Laboratory - TB Submission Form

12/2011

 

Case Review Format

12/2011

 

12 point of Tuberculosis (TB) Patient Education

04/2012

 

Tuberculosis Education Record

04/2012

 

Scaled Goal Matrix Tool

 

 

Case Management Timeline

 

 

Client Referral Form

10/2011

 

TB Worksheet - Class B1/B2 aliens