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TB Forms

1. Clinical Care
2. Correctional Facilities
3. Reporting
4. Court-Ordered Management (Quarantine)
5. Cohort Review
6. Congregate Settings
7. Phlebotomy Training
8. User Guides (TX PHIN)

Medicaid Provider Application (pdf 253 KB)


Clinical Care

Form Number Form Name Format(s) Revision Date
TB-201 Case Management Plan for Outpatient Care pdf (93 KB)  4/2012
TB-202 Tuberculosis Health Assessment/History

PDF (123 KB) 
Word (58 KB)

TB-203 Education/Counseling Record PDF (110 KB) 
Word (120 KB)
TB-204 Forms/Literature Checklist PDF (62 KB) 
Word (132 KB)
TB-205 Toxicity Assessment Word (125 KB) 5/2012
TB-206 Directly Observed Therapy Log Word (155 KB) 6/2012
TB-206A Directly Observed Therapy Log for INH/Rifapentine Word (153 KB) 8/2012
TB-207 Targeted Tuberculin Testing Screening Form Word (83 KB) 10/2014
TB-208 Tuberculosis Contact Screening Form Word (62 KB) 10/2014
TB-209               Hurricane Questionnaire Word (51 KB) 10/2012
TB-212 Clinical Assessment for Tuberculosis Medication Toxicity:  Isoniazid/Rifapentine Word  (66 KB) 10/2012
TB-220 Referral Form Word (32 KB)  8/2004
TB-231 Bacteriology TB Control PDF (33KB) 
 (62 KB)
TB-280 Chest Clinic Appointment Card Order From Warehouse  
TB-318 Positive Reactor Worksheet PDF (30 KB) 
Word (45 KB)
TB-409 Acknowledgement of Understanding (English) Word (40 KB)
TB-409A Reconocimiento de Entendimiento - Disposición de Drogas Antituberculosas Limitadas para Clientes con MTB Word (41 KB)
TB-410 Order to Implement and Carry Out Measures for a Client with TB Word (34 KB) 8/2004
TB-410A Order to Implement and Carry Out Measures for a Client with TB (Spanish) Word (44 KB) 1/2014
TB-410B Order to Implement Control Measures for Children with Tuberculosis/Orden para implementar medidas de control para niños con tuberculosis Word (33 KB) 8/2004
TB-411 Disclosure & Consent Drug Therapy TB PDF (24 KB) 
Word (53 KB)
TB-411A Formulario de Declaraciónes y Aceptación a Tratamiento de la Tuberculosis PDF (26 KB) 
 (63 KB)
TB-412 Tuberculosis Surveillance Form Order From Warehouse  
TB-415 Consent LTBI Therapy PDF (21 KB) 
Word (54 KB)
TB-415a Consent LTBI Therapy (Spanish) Word (46 KB) 8/2004
TB-415b Disclosure and Consent for Treatment of LTBI - 3HP Word (42 KB) 7/2014
TB-415c        Disclosure and Consent for Treatment of LTBI - 3HP (Spanish) Word (39 KB) 7/2014
TB-617 Preventive Treatment Record (Vietnamese) Call (512) 533-3000  
TB-618 Treatment Record (Vietnamese) Call (512) 533-3000  
TB-619 Registro de Tratamiento Call (512) 533-3000  
TB-620 Registro de Tratamiento Preventivo Call (512) 533-3000  
TB-621 Preventive Treatment Record (English) Call (512) 533-3000  
TB-622 Treatment Record (English) Call (512) 533-3000  
EF12-11494 TB Questionnaire for Children (English) Word (43 KB) 8/2004
EF12-11494A Cuestionario de Tuberculosis Para Niños Word (37 KB) 8/2004
EF12-12062 Contact Investigation Worksheet PDF (72 KB) 
 (171 KB)
EF12-12104 TB Incident Report Word (49 KB) 2/2013
EF12-12105 PPD Agreement Word (33 KB)
PDF (25 KB)
EF12-12168 Monthly TST Word (51 KB) 10/2015
EF12-12274 Adverse Drug Reaction

pdf (77 KB)
Word (45 KB)

EF12-14197 Adverse Event Form - 3HP Word (31 KB) 5/2014
EF12-14198 3HP Dosing and Symptom Monitoring Log Word  (43 KB) 5/2014
12-14685 TB Medical Hold pdf (110 KB) 10/2015
L-36 General Consent and Disclosure (English/Spanish) pdf (27 KB) 4/2010

Correctional Facilities

Form Number Form Name Format(s) Revision Date
EF12-11461 Positive Reactors/Suspects/Cases Word (54 KB) 7/2014
EF12-11462 Monthly Correctional TB Report Word (102 KB)
PDF (56 KB)
EF12-11462-I Monthly Correctional TB Report - Instructions PDF (42 KB) 6/2011
EF12-11463 Correctional Tuberculosis Screening Plan PDF (183 KB) 9/2013
EF12-12870 TB Symptom Screening Word (40 KB) 9/2014
EF12-12870A TB Symptom Screening (Spanish) Word (41 KB) 7/2014
  Prisoner in Transit Medical Summary pdf (52 KB)  
  Texas Uniform Health Status Update pdf (49 KB)  


Form Number Title Format(s) Revision Date
TB-340 Report of TB Contacts PDF (121 KB) 10/2011
TB-341 Continuation of Report of TB Contacts PDF (63 KB) 11/2011
TB-400A Report of Case and Patient Services PDF (17 KB) 11/2003
TB-400B Report of Case and Patient Services PDF (18 KB) 11/2003
EF12-11358 Binational Status Report  Word (45 KB) 11/2004
EF12-12104 TB Incident Report Word (49 KB) 3/2011
EF12-12168 Monthly TST Word (47 KB) 11/2005
  Guidelines for Congregate Setting Target Testing Word (32 KB) 5/2014
EF12-14427 Congregate Setting Target Testing Monthly Report

Word (136 KB)
Excel (34 KB)



Court Order Management

Form Number


File Size

Health Authority's Affidavit of Medical Evaluation 31 KB


Application for the Extended Management of a Person
with a Communicable Disease

40 KB
Motion for Protective Custody 34 KB
Notification of Probable Cause Hearing

30 KB


Order Appointing Attorney for Inspection, Setting, Hearing and
for Notice to Proposed Patient

28 KB


Order Appointing Special Master 27 KB


Order for Protective Custody 27 KB
Order of Continued Protective Custody and Setting
Hearing on Application
44 KB
Order for Court Reporter to Create Redacted Reporter's Records 29 KB
Order of Transport 28 KB
Waiver of Jury Trial and Right to be Present at Trial 28 KB
Order of Commitment on Application for Extended Management of
Person with Communicable Disease
32 KB


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Cohort Review

Form Number Title Format(s) Revision Date
EF12-14064 Cohort Review Presentation Form pdf  (4 MB) 11/2015
  Cohort Review Summary Form Excel (47 KB) 11/2015
EF12-14076 Cohort Review Presentation Form - Instructions pdf (114 KB) 10/2015
EF12-14077 Cohort Review Summary Form Instruction Sheet pdf (86 KB) 12/2014
  Cohort Review List of Counted Cases Word (137 KB) 11/2015

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Congregate Settings

Form Number Title Format(s) Revision Date


Tuberculosis Risk Assessment Form

pdf  (240 KB) 10/2015


Phlebotomy Training

Title Format(s) Revision Date

Phlebotomy Training Informed Consent Form

Word (51 KB)


Continuing Education Contact Hours for Phlebotomy Training

pdf (100 KB) 5/2015

Venipuncture Performance Evaluation

Word (24 KB)  4/2015

DSHS Phlebotomy Training Announcement

pdf (195 KB) 2/2016

Tuberculosis Phlebotomy Training Request

pdf (186 KB) 2/2016


User Guides

Title Format(s) Revision Date

Texas PHIN User Guide

pdf (2 MB) 2/2016

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