| Form Number |
Form Name |
Format(s) |
Revision Date |
| TB-201 |
Case Management Plan for Outpatient Care |
PDF (82.3 KB) DOC (123 KB) |
January 2008 |
| TB-202 |
Tuberculosis Health Assessment/History |
PDF (123 KB) DOC (58.2 KB) |
January 2008 |
| TB-203 |
Education/Counseling Record |
PDF (110 KB) DOC (120 KB) |
November 2007 |
| TB-204 |
Forms/Literature Checklist |
PDF (62 KB) DOC (132 KB) |
October 2008 |
| TB-205 |
Toxicity Assessment |
PDF (140 KB) DOC (168 KB) |
February 2008 |
| TB-206 |
Directly Observed Therapy Log |
PDF (109 KB) DOC (200 KB) |
November 2007 |
| TB-207 |
Targeted Tuberculin Testing Screening Form |
PDF (81.6 KB) DOC (80.5 KB) |
December 2007 |
| TB-208 |
Tuberculosis Contact Screening Form |
PDF (69.2 KB) DOC (56 KB) |
December 2007 |
| TB-220 |
Referral Form |
DOC (32 KB) |
August 2004 |
| TB-231 |
Bacteriology TB Control |
PDF (32.7KB) DOC (61.5 KB) |
January 2008 |
| TB-280 |
Chest Clinic Appointment Card |
Order From Warehouse |
|
| TB-318 |
Positive Reactor Worksheet |
PDF (29.9 KB) DOC (45 KB) |
December 2007 |
| TB-409 |
Acknowledgement of Understanding (English) |
DOC (40 KB)
|
August 2004 |
| TB-409A |
Reconocimiento de Entendimiento - Disposición de Drogas Antituberculosas Limitadas para Clientes con MTB |
DOC (41 KB)
|
August 2004 |
| TB-410 |
Order to Implement and Carry Out Measures for a Client with TB |
DOC (34 KB) |
August 2004 |
| TB-410A |
Orden para Implementar y Llevar a Cabo Medidas Para un Paciente con Tuberculosis |
DOC (38 KB) |
August 2004 |
| TB-410B |
Order to Implement Control Measures for Children with Tuberculosis/Orden para implementar medidas de control para niños con tuberculosis |
DOC (33 KB) |
August 2004 |
| TB-411 |
Disclosure & Consent Drug Therapy TB |
PDF (24 KB) DOC (53 KB) |
May 2007 |
| TB-411A |
Formulario de Declaraciónes y Aceptación a Tratamiento de la Tuberculosis |
PDF (26 KB) DOC (63 KB) |
August 2007 |
| TB-412 |
Tuberculosis Surveillance Form |
Order From Warehouse |
|
| TB-415 |
Consent LTBI Therapy |
PDF (21 KB) DOC (54 KB) |
January 2009 |
| TB-415a |
Consent LTBI Therapy (Spanish) |
DOC (46 KB) |
August 2004 |
| TB-617 |
Preventive Treatment Record (Vietnamese) |
Call (512)458-7447 |
|
| TB-618 |
Treatment Record (Vietnamese) |
Call (512)458-7447 |
|
| TB-619 |
Registro de Tratamiento |
Call (512)458-7447 |
|
| TB-620 |
Registro de Tratamiento Preventivo |
Call (512)458-7447 |
|
| TB-621 |
Preventive Treatment Record (English) |
Call (512)458-7447 |
|
| TB-622 |
Treatment Record (English) |
Call (512)458-7447 |
|
| EF12-11494 |
TB Questionnaire (English) |
DOC (43 KB) |
August 2004 |
| EF12-11494A |
Cuestionario de Tuberculosis |
DOC (37 KB) |
August 2004 |
| EF12-12062 |
Contact Investigation Worksheet |
PDF (72 KB) DOC (171 KB) |
January 2008 |
| EF12-12104 |
TB Incident Report |
DOC (49 KB) |
February 2005 |
| EF12-12105 |
PPD Agreement |
DOC (32.5 KB)
PDF (25.4 KB) |
June 2005 |
| EF12-12168 |
Monthly TST |
DOC (47 KB) |
February 2005 |
| EF12-12274 |
Adverse Drug Reaction |
PDF (45.6 KB)
DOC (46.5 KB)
|
June 2011 |
| EF12-12478 |
Genotyping Request Form |
PDF (18.2 KB) |
July 2006
|