TB Forms Resources


Consent/Control Orders Case Management Contact Investigations Cohort Review
Court Ordered Management Healthcare Personnel Correctional Facilities Targeted Testing

Consent/Control Orders

Consents: General
Document Number Title Revision Date
L-36 General Consent and Disclosure (English/Spanish) (PDF) 4/2010
L-30 Authorization to Release Confidential Medical Information (English) (PDF : 182 kB) 7/2016
L-30a Authorization to Release Confidential Medical Information (Spanish) (PDF : 196 kB) 7/2016
Consents: Medication
Document Number Title Revision Date
TB-411 Disclosure & Consent Drug Therapy TB (English) (Word : 141 kB) 1/2021
TB-411a Disclosure & Consent Drug Therapy TB (Spanish) (Word : 147 kB) 1/2021
TB-415 Consent LTBI Therapy (English) (Word : 132 kB) 1/2021
TB-415a Consent LTBI Therapy (Spanish) (Word : 133 kB) 1/2021
Control Orders
Document Number Title Revision Date
TB-409 Acknowledgement of Understanding (English) (Word : 101 kB) 8/2004
TB-409a Acknowledgement of Understanding (Spanish) (Word : 102 kB) 8/2004
TB-410 Order to Implement and Carry Out Measures for a Client with TB (English) (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 TB (Word : 25 kB) 1/2020

Case Management

Case Management: Clinical Care
Document Number Title Revision Date
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
TB-201 Case Management Plan for Outpatient Care (Word : 62 kB) 8/2017
TB-202 TB Initial Health Risk Assessment/History (PDF : 1,564 kB) 2/2020
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-209 Hurricane Questionnaire (Word : 53 kB) 8/2017
TB-231 Bacteriology TB Control (Word : 47 kB) 8/2017
TB-622 Treatment Record (English) (Word : 25 kB) 5/2017
TB-220 Referral Form (English) (Word : 31 kB) 8/2017
TB-220a Referral Form (Spanish) (Word : 36 kB) 8/2017
TB-619 Registro de Tratamiento (Word : 28 kB) 8/2017
12-12274 Adverse Drug Reaction (PDF : 156 kB) 8/2017
Resource False Positive Investigation Work Sheet (Word : 89 kB) 12/2020
Case Management: Drug Resistant TB
Document Number Title Revision Date
TB-700 TB Drug-O-Gram and Clinical Monitoring Overview (English) (Word : 82 kB) 5/2020
TB-700a TB Drug-O-Gram and Clinical Monitoring Overview (Spanish) (Word : 63 kB) 5/2020
TB-701 Drug Resistant TB Care Plan (English) (Word : 50 kB) 5/2020
TB-701a Drug Resistant TB Care Plan (Spanish) (Word : 38 kB) 5/2020
TB-702 Toxicity Assessments for Clients on Second-Line Medications (English) (Word : 354 kB) 5/2020
TB-702a Toxicity Assessments for Clients on Second-Line Medications (Spanish) (Word : 354 kB) 5/2020
TB-703 TB Bacteriology Monitoring Log (English) (Word : 34 kB) 4/2020
TB-703a TB 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) 4/2020
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) 4/2020
TB-705a Clofazimine Monitoring (Spanish) (Word : 33 kB) 5/2020
Resource Overview of Second-Line TB Medications: Side Effects and Monitoring (English) (PDF : 334 kB) 5/2020
Resource Overview of Second-Line TB Medications: Side Effects and Monitoring (Spanish) (PDF : 341 kB) 5/2020
Resource Peripheral Neuropathy Assessment (English) (PDF : 538 kB) 3/2021
Resource Peripheral Neuropathy Assessment (Spanish) (PDF : 526 kb) 3/2021
Resource Serotonin Syndrome (English) (PDF : 304 kb) 5/2020
Resource Serotonin Syndrome (Spanish) (PDF : 134 kb) 5/2020
Case Management: TB Infection
Document Number Title Revision Date
TB-206a Directly Observed Therapy Log for INH/Rifapentine (Word : 145 kB) 8/2012
12-14198 3HP Dosing and Symptom Monitoring Log (Word : 51 kB)
TB-621 Preventive Treatment Record (English) (Word : 24 kB) 8/2017
TB-620 Registro de Tratamiento Preventivo (Word : 28 kB) 5/2020
12-14197 Adverse Event Form - 3HP (Word : 28 kB) 5/2014
Case Management: Video-DOT
Document Number Title 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 : 525 kB) 8/2020
12-15763a Video DOT Medication Layout (Spanish) (PDF : 423 kB) 8/2020
12-15764 VDOT Patient Instructions (English) (Word : 32 kB) 8/2020
12-15764a VDOT Patient Instructions (Spanish) (Word : 36 kB) 8/2020
Resource Video-Enabled Directly Observed Therapy, Required and Recommended Activities (English) (PDF : 368 kB) 8/2020
Resource Video-Enabled Directly Observed Therapy, Required and Recommended Activities (Spanish) (PDF : 323 kB) 8/2020

Contact Investigations

Contact Investigations
Document Number Title Revision Date
TB-208 Tuberculosis Contact Screening Form (English) (Word : 142 kB) 10/2014
TB-208a Tuberculosis Contact Screening Form (Spanish) (Word : 67 kB) 10/2014
TB-425 TB Infectious Period Calculation Sheet (PDF : 553 kB) 4/2020
TB-460 TB Contact Investigation Expansion Analysis Check-List (Word : 198 kB) 11/2007
TB-340 Report of TB Contacts (PDF : 122 kB) 10/2011
TB-341 Continuation of Report of TB Contacts (PDF : 63 kB) 10/2011
12-12062 Contact Investigation Worksheet (Word : 112 kB) 1/2008
12-12104 TB Incident Report (PDF : 591 kB) 9/2019
12-16524 Mass Contact Roster Import Template (Excel : 12 kB) 4/2021
12-16525 Mass Contact Roster Import Data Codebook (Word : 22 kB) 4/2021

Cohort Review

Cohort Review
Document Number Title Revision Date
12-14064 Cohort Review Presentation Form (PDF : 4,963 kB) 2/2020
Resource Cohort Review Presentation Form Instructions (PDF : 115 kB) 10/2015
12-14077 Cohort Review Summary Form (Excel : 52 kB) 2/2020
Resource Cohort Review Summary Form Instruction Sheet (PDF : 86 kB) 12/2014
Resource Cohort Review List of Counted Cases (Word : 62 kB) 10/2019
Resource Cohort Review Infrastructure (PDF : 67 kB) 4/2013

Court Ordered Management

Court Ordered Management
Document Number Title Revision Date
84004_1 Order of Transport (Word : 33 kB)
84044_1 Waiver of Jury Trial and Right to be Present at Trial (Word : 33 kB)
84053_1 Order of Commitment on Application for Extended Management of Person with Communicable Disease (Word : 38 kB)
86749_1 Health Authority's Affidavit of Medical Evaluation (Word : 37 kB)
86963_1 Application for the Extended Management of a Person with a Communicable Disease (Word : 46 kB)
86964_1 Motion for Protective Custody (Word : 39 kB)
86965_1 Order Appointing Special Master (Word : 33 kB)
86966_1 Notification of Probable Cause Hearing (Word : 38 kB)
86968_1 Order for Protective Custody (Word : 36 kB)
86969_1 Order of Continued Protective Custody and Setting Hearing on Application (Word : 48 kB)
86970_1 Order Appointing Attorney for Inspection, Setting, Hearing and for Notice to Proposed Patient (Word : 34 kB)
86972_1 Order for Court Reporter to Create Redacted Reporter's Records (Word : 45 kB)

Healthcare Personnel

Healthcare Personnel
Document Number Title Revision Date
TB-600 Baseline TB Assessment for HCP (PDF : 127 kB) 3/2020
TB-601 After Hire TB Assessment for HCP (PDF : 66 kB) 3/2020
TB-602 TB Screening Results and Work Clearance for HCP (PDF : 141 kB) 3/2020

Correctional Facilities

Correctional Facilities
Document Number Title Revision Date
TB-430 Social History Interview for Correctional Settings (Word : 67 kB) 6/2018
TB-800 Correctional TB Risk Assessment (PDF : 753 kB) 6/2017
TB-805 Correctional TB Screening Plan (PDF : 415 kB) 4/2019
TB-805-I Correctional TB Screening Plan - Instructions (PDF : 403 kB) 5/2017
TB-810 Tuberculosis Symptoms Screening Form (English) (PDF : 118 kB) 4/2017
TB-810-E Tuberculosis Symptoms Screening Form (Spanish) (PDF : 115 kB) 4/2017
TB-815 Tuberculosis Medical Hold (PDF : 269 kB) 8/2018
12-11461 Positive Reactors/Suspects/Cases (Word : 20 kB) 11/2015
12-11461-I Positive Reactors/Suspects/Cases - Instructions (PDF : 98 kB) 5/2019
12-11462 Monthly Correctional TB Report (Word : 22 kB) 10/2015
12-11462-I Monthly Correctional TB Report - Instructions (PDF : 42 kB) 5/2019
Resource Prisoner in Transit Medical Summary (PDF : 52 kB) 2/2015
Resource Texas Uniform Health Status Update (PDF : 54 kB) 11/2004
Resource Tubersol Request Form for CH89 Facilities

Targeted Testing

Targeted Testing: General
Document Number Title Revision Date
TB-207 Targeted Tuberculin Testing Screening Form (Word : 162 kB) 10/2014
Targeted Testing: Children
Document Number Title Revision Date
TB-318 Positive Reactor Worksheet (Word : 120 kB) 12/2017
12-11494 TB Questionnaire for Children (English) (Word : 20 kB) 3/2020
12-11494a TB Questionnaire for Children (Spanish) (Word : 22 kB) 8/2004
Targeted Testing: Congregate Settings
Document Number Title Revision Date
TB-500 TB Risk Assessment Form (PDF : 539 kB) 10/2017
TB-505 Environmental Risk Assessment for Congregate Settings (PDF : 549 kB) 6/2018
12-14427 Congregate Setting Target Testing Monthly Report (Word : 36 kB) 5/2014
Resource Guidelines for Congregate Setting Target Testing (Word : 33 kB) 5/2014
Targeted Testing: Tubersol Forms
Document Number Title Revision Date
12-12105 PPD Agreement (Word : 103 kB) 6/2005
12-12168 Monthly TST (Word : 19 kB) 10/2015



Last updated April 9, 2021