| Form Number |
Form Name |
Format(s) |
Revision Date |
| TB-201 |
Case Management Plan for Outpatient Care |
 (93 KB) |
4/2012 |
| TB-202 |
Tuberculosis Health Assessment/History |
PDF (123 KB)  (58.2 KB)
|
1/2008 |
| TB-203 |
Education/Counseling Record |
PDF (110 KB)
(120 KB) |
1/2007 |
| TB-204 |
Forms/Literature Checklist |
PDF (62 KB) (132 KB) |
10/2008 |
| TB-205 |
Toxicity Assessment |
(125 KB) |
5/2012 |
| TB-206 |
Directly Observed Therapy Log |
(155 KB) |
6/2012 |
| TB-206A |
Directly Observed Therapy Log for INH/Rifapentine |
(153 KB) |
8/2012 |
| TB-207 |
Targeted Tuberculin Testing Screening Form |
PDF (81.6 KB) (80.5 KB) |
12/2007 |
| TB-208 |
Tuberculosis Contact Screening Form |
PDF (69.2 KB) (56 KB) |
12/2007 |
| TB-209 |
Hurricane Questionnaire |
(51 KB) |
10/2012 |
| TB-212 |
Clinical Assessment for Tuberculosis Medication Toxicity: Isoniazid/Rifapentine |
(66 KB) |
10/2012 |
| TB-220 |
Referral Form |
(32 KB) |
8/2004 |
| TB-231 |
Bacteriology TB Control |
PDF (32.7KB) (61.5 KB) |
1/2008 |
| TB-280 |
Chest Clinic Appointment Card |
Order From Warehouse |
|
| TB-318 |
Positive Reactor Worksheet |
PDF (29.9 KB) (45 KB) |
12/2007 |
| TB-409 |
Acknowledgement of Understanding (English) |
(40 KB)
|
8/2004 |
| TB-409A |
Reconocimiento de Entendimiento - Disposición de Drogas Antituberculosas Limitadas para Clientes con MTB |
(41 KB)
|
8/2004 |
| TB-410 |
Order to Implement and Carry Out Measures for a Client with TB |
(34 KB) |
8/2004 |
| TB-410A |
Orden para Implementar y Llevar a Cabo Medidas Para un Paciente con Tuberculosis |
(38 KB) |
8/2004 |
| TB-410B |
Order to Implement Control Measures for Children with Tuberculosis/Orden para implementar medidas de control para niños con tuberculosis |
(33 KB) |
8/2004 |
| TB-411 |
Disclosure & Consent Drug Therapy TB |
PDF (24 KB) (53 KB) |
5/2007 |
| TB-411A |
Formulario de Declaraciónes y Aceptación a Tratamiento de la Tuberculosis |
PDF (26 KB) (63 KB) |
8/2007 |
| TB-412 |
Tuberculosis Surveillance Form |
Order From Warehouse |
|
| TB-415 |
Consent LTBI Therapy |
PDF (21 KB) (54 KB) |
1/2009 |
| TB-415a |
Consent LTBI Therapy (Spanish) |
(46 KB) |
8/2004 |
| TB-415b |
Disclosure and Consent for Treatment of LTBI - INH/Rifapentine |
(42 KB) |
10/2012 |
| 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) |
(43 KB) |
8/2004 |
| EF12-11494A |
Cuestionario de Tuberculosis Para Niños |
(37 KB) |
8/2004 |
| EF12-12062 |
Contact Investigation Worksheet |
PDF (72 KB) (171 KB) |
1/2008 |
| EF12-12104 |
TB Incident Report |
(49 KB) |
2/2013 |
| EF12-12105 |
PPD Agreement |
(32.5 KB)
PDF (25.4 KB) |
6/2005 |
| EF12-12168 |
Monthly TST |
(47 KB) |
2/2005 |
| EF12-12274 |
Adverse Drug Reaction |
PDF (45.6 KB)
(46.5 KB)
|
6/2011 |