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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) – print pp. 1-3 revised 09/2008


         Follow-up Report 1 – print p. 4 revised 09/2008


         Follow-up Report 2 –  print pp.5-6 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 Symptom Screen (English)


TB Risk Assessment (English)