TB Public Health Clinic Forms - Related Links
TB Public Health Clinic Forms
Reporting & Notification Forms
3140
New
TB Suspect Referral
(revised 03/2015)
3141
Initial Report on Patient with TB
(revised 2/2020)
3142
Follow-up
Report on Patient with TB
(revised 2/2020)
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 10/2016)
English
,
Bhutanese
,
Burmese
,
Chinese
,
Farsi
,
Korean
,
Nepali
,
DPH04/328HW Medication Information (revised 10/2016)
English
,
Bhutanese
,
Burmese
,
Chinese
,
Farsi
,
Korean
,
Nepali
,
Spanish
, Vietnamese
3575 Refusal of Care Form - TB Program (revised 10/2016)
English
,
Bhutanese
,
Burmese
,
Chinese
,
Farsi
,
Korean
,
Nepali
,
3609.LTBI LTBI Consent and Treatment Plan - Latent TB Infection (revised 10/2016)
English,
Bhutanese
,
Burmese
,
Chinese
,
Farsi
,
Korean
,
Nepali
,
3609.TB Consent to Treatment - Active TB Case/Suspect (revised 10/2016)
English,
Bhutanese
,
Burmese
,
Chinese
,
Farsi
,
Korean
,
Nepali
,
603.DOT Directly Observed Therapy (DOT) Agreement for TB Treatment (revised 10/2016)
English,
Bhutanese
,
Burmese
,
Chinese
,
Farsi
,
Korean
,
Nepali
,
603.LTBI
Consent and Treatment Plan for Latent Tuberculosis Infection (LTBI) with Directly Observed Therapy
(revised 2/2020)
603.VDOT.TB
Video Observed Therapy Agreement for Active Tuberculosis Disease Treatment
(Revised 2/25/2020)
603.VDOT.LTBI
Video Observed Therapy Agreement for Latent TB Infection Treatment
(Revised 2/25/2020)
604
DOT
Provider Agreement (revised 2/2017)
Case Management/Clinic Forms
3121-R
Tuberculosis Services
(revised 2/25/2020)
3126
Contact
Investigation Report
(revised 10/2016)
3130
DOT Medication Sheet
(revised 2/25/2020)
INH-RPT
Isoniazid/Rifapentine
Reporting & DOT
(revised 10/2012)
Instructions
for INH/RPT Reporting form
(revised 10/2012)
3135
Tuberculosis Flowsheet
(revised 2/25/2020)
TB/HIV
TB/HIV Flowsheet
(revised 2/25/2020)
DPH04/324
MDR-TB
Flowsheet
(revised 12/2011)
2nd
Line Second Line Therapy Authorization Form
(revised 10/2020)
HAIN
HAIN
Rapid TB Diagnostic & Resistance Submission Form
(revised 12/2011)
3143
Bacteriologic
Examinations Record
(revised 12/2011)
Medical
Case Review
(revised 2/25/2020)
Case Review Note and Medical Recommendation Letter (created 2/25/2020)
12
point of Tuberculosis (TB) Patient Education
(revised 08/2015)
Tuberculosis
Education Record
(revised 04/2012)
Case
Management Timeline (revised June 2020)
Client
Referral Form
(revised 10/2011)
TB
Worksheet - Class B1/B2, aliens
Refusal
of HIV Testing form
(revised 10/2016)
TB Assessments
Tuberculosis
Risk Assessment and Symptom Screen (new 2020, English only)
Tuberculosis (TB) Symptom Screen (revised 10/2016)
English
,
Bosnian
,
Somali
,
Spanish,
Vietnamese
Tuberculosis (TB) Risk Assessment (revised 10/2016)
English
,
Bosnian
,
Somali
,
Spanish
,
Vietnamese
Pediatric Tuberculosis (TB) Risk Assessment
English,
Spanish
(revised 10/2016)
Page last updated 6/16/2022
TB Audit Tools
TB
Case Audit Tool (posted 9/2020)
LTBI
Audit Tool (posted 9/2020)
TB Public Health Clinic Forms - Related Links