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  • Contact Us

    TB and Hansen's Disease Branch

    MC 1939
    P.O. Box 149347
    Austin, TX 78756-9347

    Phone: 737-255-4300
    Fax: 512-989-4010


    Email the TB Program

TB Forms


Types of Forms:

  1. Clinical Care Forms
  2. Clinical Care Resources for Clients with Drug Resistant TB and Clients on Second-Line Medications
  3. Video-Enabled Directly Observed Therapy
  4. New Resource Materials
  5. Correctional Facilities
  6. Reporting
  7. Court-Ordered Management (Quarantine)
  8. Cohort Review
  9. Congregate Settings
  10. Health Care Personnel
  11. Phlebotomy Training
  12. Notice of Change in TB Personnel (PDF : 119 kB)
  13. Instructions to Access Tuberculosis Program Databases (PDF : 559 kB)
  14. Medicaid Provider Application (PDF : 152 kB)


Clinical Care Forms

Form Number Title Format(s) Revision Date
TB-201 Case Management Plan for Outpatient Care Word 62 kB 8/2017
TB-202 TB Initial Health Risk Assessment/History PDF 1,565 kB 3/2020
TB-203 Education/Counseling Record Word 115 kB 8/2017
TB-204 Forms/Literature Checklist Word 185 kB 10/2008
TB-205 Toxicity Assessment Word 127 kB 8/2017
TB-206 Directly Observed Therapy Log Word 174 kB 8/2017
TB-206A Directly Observed Therapy Log for INH/Rifapentine Word 145 kB 8/2012
EF12-14198 3HP Dosing and Symptom Monitoring Log Word 53 kB   
TB-207 Targeted Tuberculin Testing Screening Form Word 162 kB 10/2014
TB-208 Tuberculosis Contact Screening Form Word 142 kB 10/2014
TB-209 Hurricane Questionnaire Word 53 kB 8/2017
TB-220 Referral Form Word 31 kB 8/2017
TB-231 Bacteriology TB Control Word 47 kB 8/2017
TB-318 Positive Reactor Worksheet Word 120 kB 12/2007
L-36 General Consent and Disclosure (English/Spanish) PDF 27 kB 4/2010
TB-409 Acknowledgement of Understanding (English) Word 111 kB 8/2004
TB-409a Reconocimiento de Entendimiento - Disposición de Drogas Antituberculosas Limitadas para Clientes con MTB Word 1,733 kB 8/2004
TB-410 Order to Implement and Carry Out Measures for a Client with TB Word 38 kB 1/2020
TB-410a Order to Implement and Carry Out Measures for a Client with TB (Spanish) Word 41 kB 1/2020
TB-410b Order to Implement Control Measures for Children with Tuberculosis/Orden para implementar medidas de control para niños con tuberculosis Word 25 kB 1/2020
TB-411 Disclosure & Consent Drug Therapy TB Word 139 kB 6/2020
TB-411a Formulario de Declaraciónes y Aceptación a Tratamiento de la Tuberculosis Word 146 kB 6/2020
TB-415 Consent LTBI Therapy Word 118 kB 1/2009
TB-415a Consent LTBI Therapy (Spanish) Word 124 kB 8/2004
TB-415b Disclosure and Consent for Treatment of LTBI - 3HP Word 37 kB 7/2014
TB-415c Disclosure and Consent for Treatment of LTBI - 3HP (Spanish) Word 35 kB 7/2014
TB-425 Tuberculosis Infectious Period Calculation Sheet PDF 553 kB 4/2020
TB-430 Social History Interview for Correctional Settings Word 65.7 kB 6/2018
TB-505 Environmental Risk Assessment for Congregate Settings  PDF 548.8 kB 7/2018 
TB-619 Registro de Tratamiento Word 28 kB 8/2017
TB-620 Registro de Tratamiento Preventivo Word 107 kB 5/2017
TB-621 Preventive Treatment Record (English) Word 23 kB 8/2017
TB-622 Treatment Record (English) Word 121 kB 5/2017
EF12-11494 TB Questionnaire for Children (English) Word 20 kB 3/2020
EF12-11494a Cuestionario de Tuberculosis Para Niños Word 22 kB 8/2020
EF12-12062 Contact Investigation Worksheet Word 223 kB 1/2008
EF12-12104 TB Incident Report PDF 595 kB 9/2019
EF12-12105 PPD Agreement Word 114 kB 6/2005
EF12-12274 Adverse Drug Reaction PDF 156 kB 8/2017
EF12-14197 Adverse Event Form - 3HP Word 32 kB 5/2014


Clinical Care Resources for Clients with Drug Resistant TB and Clients on Second-Line Medications

Form Number Title Format(s) Revision Date
TB-700 Tuberculosis Drug-O-Gram and Clinical Monitoring Overview (English)
Word 82 kB 5/2020
TB-700a Tuberculosis Drug-O-Gram and Clinical Monitoring Overview (Spanish)
Word 63 kB 5/2020
TB-701 Drug Resistant Tuberculosis Care Plan (English)
Word 50 kB 5/2020
TB-701a Drug Resistant Tuberculosis Care Plan (Spanish)
Word 38 kB 5/2020
TB-702 Toxicity Assessments for Clients on Second-Line Medications (English)
Word 354 kB 9/2020
TB-702a Toxicity Assessments for Clients on Second-Line Medications (Spanish)
Word 354 kB 9/2020
TB-703 Tuberculosis Bacteriology Monitoring Log (English)
Word 34 kB 5/2020
TB-703a Tuberculosis Bacteriology Monitoring Log (Spanish)
Word 33 kB  5/2020
TB-704 Tuberculosis Directly Observed Therapy (DOT) Log for Clients on Second-Line Medications (English)
Word 88 kB 5/2020
TB-704a Tuberculosis Directly Observed Therapy (DOT) Log for Clients on Second-Line Medications (Spanish)
Word 91 kB 5/2020
TB-705 Clofazimine Monitoring (English)
Word 28 kB 5/2020
TB-705a Clofazimine Monitoring (Spanish) 
Word 33 kB 5/2020

Overview of Second-Line TB Medications: Side Effects and Monitoring (English)
PDF 334 kB 9/2020

Overview of Second-Line TB Medications: Side Effects and Monitoring (Spanish)
PDF 341 kB 9/2020

Peripheral Neuropathy Assessment Procedure (English)
PDF 286 kB 5/2020

Peripheral Neuropathy Assessment Procedure (Spanish)
PDF 275 kB 5/2020

Serotonin Syndrome (English)
PDF 304 kB 5/2020

Serotonin Syndrome (Spanish)
PDF 134 kB 5/2020

Bedaquiline Ordering Process                
PDF 607 kB 9/2020


Video-Enabled Directly Observed Therapy

Form Number Title Format(s) Revision Date
12-15760
Mobile Application English
PDF 333 kB 5/2020
12-15760A
Mobile Application Spanish
PDF 335 kB 5/2020
12-15761
VDOT Mobile Phone User Agreement English
Word 25 kB 4/2020
12-15761A
VDOT Mobile Phone User Agreement Spanish
Word 23 kB 4/2020
12-15762
VDOT Client Participation Agreement English  Word 39 kB 4/2020
12-15762A
VDOT Client Participation Agreement Spanish
Word 40 kB 4/2020
12-15763 Video DOT Medication Layout English
PDF 129 kB 10/2017
12-15763A
Video DOT Medication Layout Spanish
PDF 474 kB 10/2017
12-15764
VDOT Patient Instructions EnglishWord 32 kB8/2020 
12-15764A
VDOT Patient Instructions Spanish Word 36 kB8/2020


New Resource Materials

Form Number Title Format(s) Revision Date
False Positive Investigation Work Sheet Word 87 kB 8/2017
Therapeutic Drug Monitoring Process PDF 630 kB 9/2019
TB-905 Tuberculin Skin Test Competency Check-List Word 72 kB 8/2017
TB-460 TB Contact Investigation Expansion Analysis Check-List Word 198 kB 11/2017


Correctional Facilities

Form Number Title Format(s) Revision Date
EF12-11461 Positive Reactors/Suspects/Cases Word 60 kB 11/2015
EF12-11461-I Positive Reactors/Suspects/Cases - Instructions PDF 98 kB 5/2019
EF12-11462 Monthly Correctional TB Report Word 27 kB
PDF 180 kB
10/2015
EF12-11462-I Monthly Correctional TB Report - Instructions PDF 42 kB 5/2019
TB-800 Correctional TB Risk Assessment PDF 712 kB
6/2017
TB-805 Correctional TB Screening Plan PDF 415 kB 4/2019
TB-805-I Correctional TB Screening Plan - Instructions PDF 402 kB 5/2017
TB-810 Tuberculosis Symptom Screening Form PDF 118 kB 4/2017
TB-810-E Tuberculosis Symptom Screening Form (Spanish) PDF 115 kB 4/2017
TB-815 Tuberculosis Medical Hold PDF 269 kB 8/2018 
Prisoner in Transit Medical Summary PDF 52 kB*
Texas Uniform Health Status Update PDF 49 kB
* save the file to your computer to view (right click and save as)


Reporting

Form Number Title Format(s) Revision Date
TB-340 Report of TB Contacts PDF 122 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 1,847 kB 4/2020
TB-400B Report of Case and Patient Services PDF 1,102 kB 4/2020
EF12-11358 Binational Status Report Word 45 kB 11/2004
EF12-12168 Monthly TST Word 47 kB 11/2005
Guidelines for Congregate Setting Target Testing Word 33 kB 5/2014
EF12-14427 Congregate Setting Target Testing Monthly Report Word 137 kB
Excel 35 kB
5/2014


Court Order Management

Form Number Title Format(s) Revision Date
86749_1 Health Authority's Affidavit of Medical Evaluation Word 31 kB
86963_1 Application for the Extended Management of a Person with a Communicable Disease Word 40 kB
86964_1 Motion for Protective Custody Word 34 kB
86966_1 Notification of Probable Cause Hearing Word 30 kB
86970_1 Order Appointing Attorney for Inspection, Setting, Hearing and for Notice to Proposed Patient Word 28 kB
86965_1 Order Appointing Special Master Word 27 kB
86968_1 Order for Protective Custody Word 27 kB
86969_1 Order of Continued Protective Custody and Setting Hearing on Application Word 44 kB
86972_1 Order for Court Reporter to Create Redacted Reporter's Records Word 29 kB
84004_1 Order of Transport Word 28 kB
84044_1 Waiver of Jury Trial and Right to be Present at Trial Word 28 kB
84053_1 Order of Commitment on Application for Extended Management of Person with Communicable Disease Word 32 kB


Cohort Review

Form Number Title Format(s) Revision Date
EF12-14064 Cohort Review Presentation Form PDF 4,963 kB 2/2020
Cohort Review Summary Form Excel 52 kB 2/2020

Cohort Review Presentation Form - Instructions PDF 115 kB 10/2015
EF12-14077 Cohort Review Summary Form Instruction Sheet PDF 86 kB 12/2014
Cohort Review List of Counted Cases Word 62 kB 10/2019

Congregate Settings

Form Number Title Format(s) Revision Date
TB-500 Tuberculosis Risk Assessment Form  PDF 539 kB 10/2017


Health Care Personnel

Form Number Title Format(s) Revision Date
TB-600 Baseline Tuberculosis Assessment for Health Care Personnel
PDF 163 kB 3/2020
TB-601 After Hire Tuberculosis Assessment for Health Care Personnel
PDF 96 kB 3/2020
TB-602 Tuberculosis Screening Results and Work Clearance for Health Care Personnel
PDF 206 kB 3/2020


Phlebotomy Training

Form Number

Title

Format(s) Revision Date
  Phlebotomy Training Informed Consent Form Word 51 kB 5/2015
 

Continuing Education Contact Hours for Phlebotomy Training

PDF 101 kB 9/2017
EF13-14599
Venipuncture Performance Evaluation Word 25 kB 4/2015
  DSHS Phlebotomy Class Announcement PDF 299 kB 10/2016
  Tuberculosis Phlebotomy Class Request PDF 1,028 kB 10/2016



Last updated October 29, 2020