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
,
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 (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)