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)

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

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

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

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

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

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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)

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

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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)