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Tuberculosis Control Forms

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Active Tuberculosis Disease (ATBD) / Suspect
Case Management Forms
Contact Investigations
Lab (Unified State Laboratories: Public Health)
Latent Tuberculosis Infection (LTBI)
Monthly Reports
Quarantine / Isolation
Tuberculin Skin Testing
X-Rays
Miscellaneous

Active Tuberculosis Disease (ATBD) / Suspect

Active TB Disease Treatment Agreement (2011)
Consent for Treatment of Tuberculosis - Preventive and First-Line Medications (March 2012)
Consent for Treatment of Tuberculosis - Second-Line Medications (March 2012)
Consent Form for Treatment of Tuberculosis (Spanish) [May 2009]
Consent Form for Treatment of Tuberculosis (Vietnamese) [June 2009]
Daily Observed Therapy Tracking Sheets (2012)
Daily Observed Therapy Tracking Sheets (2013)
INH Questionnaire (2009)
Managing Persons At-Risk for Flight (June 2010)
Monthly TB Drug Monitoring for Toxicities (1997)
Post-Treatment Evaluation Form (2007)
Referral & Report
RVCT - Report of Verified Case of Tuberculosis (September 2008)
TB Suspect and Case Log (2012)
TB Treatment Completion Record / TB Card

Case Management Forms

Authorization to Release Medical Records (2000)
Interjurisdictional TB Notification Form (September 2010)
Interjurisdictional TB Notification Follow-Up Form (September 2010)
TB Client Progress Notes

Contact Investigations

Lab

Instructions for TB Lab Test Request Form (2012)
Tuberculosis Lab Test Request Form (2012)
QuantiFERON Fact Sheet (2007)
Unified State Laboratories: Public Health

Latent Tuberculosis Infection (LTBI)

3HP DOT Log (October 2012)
Consent for Treatment of Tuberculosis - Preventive and First-Line Medications (March 2012)
Consent Form for Treatment of Tuberculosis (Spanish) [May 2009]
Consent Form for Treatment of Tuberculosis (Vietnamese) [June 2009]
INH Questionnaire (2009)
LTBI Treatment Refusal Form (2009)
TB Treatment Completion Record / TB Card

Monthly Reports

Instructions for Monthly TB Activity Report (January 2010)
Monthly TB Activity Report
Monthly TB Test Report
Monthly Pharmacy Inventory

Quarantine/Isolation

Court-Ordered Treatment and Involuntary Isolation Guidelines for the Control of Tuberculosis (February 2009)

See pages 16 and 17 for links to forms
All of the forms are Microsoft Word files

This document contains links to forms needed for the following categories:

Initial Orders and Affidavits
Stipulated Orders
In Case of Evidentiary Hearing
Request and Order to Extend Isolation and Treatment Time
Treatment Complete and Release of Individual
Reference Materials

Tuberculin Skin Testing

Monthly TB Test Report
Consent for Tuberculin Skin Test (January 2013)
TB Screening Form (January 2013)
TB Screening Form for Past Reactive Testing (October 2010)
Tuberculin Skin Testing Worksheet

X-Rays

Instructions for Requesting X-Ray at Primary Children’s Medical Center (June 2010)

X-Ray Request Form for Primary Children’s Medical Center (June 2010)

Request for X-Ray Interpretation (2001)

Miscellaneous

Cohort Review Form
Site Visit Tool (2009)

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