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 ,

          Spanish ,  Vietnamese

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 ,

          Spanish ,  Vietnamese

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

          English ,  Bhutanese , Burmese ,  Chinese ,  Farsi ,  Korean ,  Nepali ,

       Spanish ,  Vietnamese

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

          English ,  Bhutanese , Burmese ,  Chinese ,  Farsi , Korean ,  Nepali ,

          Spanish ,  Vietnamese

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

          English ,  Bhutanese , Burmese ,  Chinese ,  Farsi ,  Korean ,  Nepali ,

          Spanish ,  Vietnamese

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)

Scaled Goal Matrix Tool

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 01/19/2017

TB Audit Tools

TB Case Audit Tool (posted 9/2020)

LTBI Audit Tool (posted 9/2020)

TB Public Health Clinic Forms - Related Links

TB Public Health Clinic Forms - Related Links

• Mycobacteriology Lab Form