Reporting & Notification Forms
3140 New TB Suspect Referral (revised 03/2015)
3141 Initial Report on Patient with TB (revised 10/2016)
3142 Follow-up Report on Patient with TB (revised 10/2016)
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 10/2016)
603.VDOT.TB Video Observed Therapy Agreement for Active Tuberculosis Disease Treatment (created 01/2017)
603.VDOT.LTBI Video Observed Therapy Agreement for Latent TB Infection Treatment (created 01/2017)
Case Management/Clinic Forms
3121-R Tuberculosis Services (revised 10/2016)
3126 Contact Investigation Report (revised 10/2016)
3130 DOT Medication Sheet (revised 10/2016)
INH-RPT Isoniazid/Rifapentine Reporting & DOT (revised 10/2012)
Instructions for INH/RPT Reporting form (revised 10/2012)
3135 Tuberculosis Flowsheet (revised 10/2016)
TB/HIV TB/HIV Flowsheet (revised 12/2011)
DPH04/324 MDR-TB Flowsheet (revised 12/2011)
2nd Line Second Line Therapy Authorization Form (revised 10/2016)
HAIN HAIN Rapid TB Diagnostic & Resistance Submission Form (revised 12/2011)
3143 Bacteriologic Examinations Record (revised 12/2011)
Case Review Format (revised 10/2016)
12 point of Tuberculosis (TB) Patient Education (revised 08/2015)
Tuberculosis Education Record (revised 04/2012)
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