TB Public Health Clinic Forms

Reporting & Notification Forms

3140 Download this pdf file.New TB Suspect Referral (revised 03/2015)

3141 Download this pdf file. Initial Report on Patient with TB (revised 2/2020)

3142 Download this pdf file.Follow-up Report on Patient with TB (revised 2/2020)

NTCA 3-2002 Interjurisdictional Tuberculosis Notification 

         Download this pdf file.Notification Form (revised 05/2015)

          Download this pdf file.Follow-up Form (revised 11/2014)

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

Legal Forms

3144 Active Tuberculosis (TB) Treatment Plan (revised 10/2016)

         Download this pdf file.English Download this pdf file.Bhutanese Download this pdf file.Burmese Download this pdf file.Chinese , Download this pdf file.Farsi , Download this pdf file.Korean Download this pdf file.Nepali ,

          Download this pdf file.Spanish Download this pdf file.Vietnamese

DPH04/328HW Medication Information (revised 10/2016)

         Download this pdf file.English Download this pdf file.Bhutanese , Download this pdf file.Burmese Download this pdf file.Chinese , Download this pdf file.Farsi , Download this pdf file.Korean Download this pdf file.Nepali ,

          Download this pdf file.Spanish Download this pdf file.Vietnamese

3575 Refusal of Care Form - TB Program (revised 10/2016)

         Download this pdf file.English , Download this pdf file.Bhutanese Download this pdf file.Burmese Download this pdf file.Chinese Download this pdf file.Farsi , Download this pdf file.Korean Download this pdf file.Nepali ,

          Download this pdf file.Spanish Download this pdf file.Vietnamese

3609.LTBI LTBI Consent and Treatment Plan - Latent TB Infection (revised 10/2016)

          Download this pdf file.English Download this pdf file.Bhutanese , Download this pdf file.Burmese Download this pdf file.Chinese Download this pdf file.Farsi Download this pdf file.Korean Download this pdf file.Nepali ,

       Download this pdf file.Spanish Download this pdf file.Vietnamese

3609.TB Consent to Treatment - Active TB Case/Suspect (revised 10/2016)

          Download this pdf file.English Download this pdf file.Bhutanese , Download this pdf file.Burmese Download this pdf file.Chinese Download this pdf file.Farsi , Download this pdf file.Korean Download this pdf file.Nepali ,

          Download this pdf file.Spanish Download this pdf file.Vietnamese

603.DOT Directly Observed Therapy (DOT) Agreement for TB Treatment (revised 10/2016)

          Download this pdf file.English Download this pdf file.Bhutanese , Download this pdf file.Burmese Download this pdf file.Chinese Download this pdf file.Farsi Download this pdf file.Korean Download this pdf file.Nepali ,

          Download this pdf file.Spanish Download this pdf file.Vietnamese

Download this pdf file.603.LTBI Consent and Treatment Plan for Latent Tuberculosis Infection (LTBI) with Directly Observed Therapy (revised 2/2020)

Download this pdf file.603.VDOT.TB Video Observed Therapy Agreement for Active Tuberculosis Disease Treatment (Revised 2/25/2020)

Download this pdf file.603.VDOT.LTBI Video Observed Therapy Agreement for Latent TB Infection Treatment (Revised 2/25/2020)

604 Download this pdf file.DOT Provider Agreement (revised 2/2017)

Case Management/Clinic Forms

Download this pdf file.3121-R Tuberculosis Services (revised 2/25/2020)

3126 Download this pdf file.Contact Investigation Report (revised 10/2016)

Download this pdf file.3130 DOT Medication Sheet (revised 2/25/2020)

INH-RPT Download this pdf file.Isoniazid/Rifapentine Reporting & DOT (revised 10/2012)

Download this pdf file.Instructions for INH/RPT Reporting form (revised 10/2012)

Download this pdf file.3135 Tuberculosis Flowsheet Download this pdf file. (revised 2/25/2020)

Download this pdf file.TB/HIV TB/HIV Flowsheet (revised 2/25/2020)

DPH04/324 Download this pdf file.MDR-TB Flowsheet (revised 12/2011)

Download this pdf file.2nd Line Second Line Therapy Authorization Form (revised 10/2020)

HAIN Download this pdf file.HAIN Rapid TB Diagnostic & Resistance Submission Form (revised 12/2011)

3143 Download this pdf file.Bacteriologic Examinations Record (revised 12/2011)

Download this pdf file.Medical Case Review  (revised 2/25/2020)

Case Review Note and Medical Recommendation Letter (created 2/25/2020)

Download this pdf file.12 point of Tuberculosis (TB) Patient Education (revised 08/2015)

Download this pdf file.Tuberculosis Education Record (revised 04/2012)

Download this pdf file.Scaled Goal Matrix Tool

Download this pdf file.Case Management Timeline (revised June 2020)

Download this pdf file.Client Referral Form (revised 10/2011)

Download this pdf file.TB Worksheet - Class B1/B2, aliens

Download this pdf file.Refusal of HIV Testing form (revised 10/2016)

TB Assessments

Tuberculosis (TB) Symptom Screen (revised 10/2016)

Download this pdf file.English Download this pdf file.Bosnian , Download this pdf file.Somali Download this pdf file.Spanish Download this pdf file.Vietnamese

Tuberculosis (TB) Risk Assessment (revised 10/2016)

Download this pdf file.English Download this pdf file.Bosnian , Download this pdf file.Somali Download this pdf file.Spanish , Download this pdf file.Vietnamese

Pediatric Tuberculosis (TB) Risk Assessment  Download this pdf file.English Download this pdf file.Spanish (revised 10/2016)

Page last updated 01/19/2017

TB Audit Tools

Download this pdf file.TB Case Audit Tool (posted 9/2020)

Download this pdf file.LTBI Audit Tool (posted 9/2020)