TB Public Health Clinic Forms

Reporting & Notification Forms


3140 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 


         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)


         EnglishBhutaneseBurmeseChinese, Farsi, KoreanNepali,


         SpanishVietnamese


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


         EnglishBhutanese,BurmeseChinese,Farsi, KoreanNepali,


         SpanishVietnamese


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


         English, BhutaneseBurmeseChineseFarsi, KoreanNepali,


         SpanishVietnamese


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


         EnglishBhutanese,BurmeseChineseFarsiKoreanNepali,


       SpanishVietnamese


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


         EnglishBhutanese, BurmeseChineseFarsi, KoreanNepali,


         SpanishVietnamese


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


         EnglishBhutanese,BurmeseChineseFarsiKoreanNepali,


         SpanishVietnamese


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)


Case Management/Clinic Forms


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


3126 Contact Investigation Report (revised 10/2016)


Download this pdf file.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)


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


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


DPH04/324 MDR-TB Flowsheet (revised 12/2011)


Download this pdf file.2nd Line Second Line Therapy Authorization Form (revised 2/25/2020)


HAIN HAIN Rapid TB Diagnostic & Resistance Submission Form (revised 12/2011)


3143 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)


12 point of Tuberculosis (TB) Patient Education (revised 08/2015)


Tuberculosis Education Record (revised 04/2012)


Scaled Goal Matrix Tool


Download this pdf file.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 (TB) Symptom Screen (revised 10/2016)


EnglishBosnian,SomaliSpanishVietnamese


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


EnglishBosnian, SomaliSpanish, Vietnamese


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


Page last updated 01/19/2017