TB Program HomeAbout UsAbout TuberculosisHow To Report TBTB News and AnnouncementsFAQs
TB Data and Statistics
Resources for Healthcare ProfessionalsTB Binational Program
TB Funded Programs
TB FormsCorrectional FacilitiesEducation, Training and Resources
THISISTHISIS Training and ImplementationHansen's DiseaseHIV/STD ProgramTB/HIV/STD Section


  • DSHS TB and Hansen's Disease Branch
    Post Office Box 149347, MC 1873
    Austin, TX 78714

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

    Email the TB Program

    Email data requests to the TB Program

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) 7/2016
L-30a Authorization to Release Confidential Medical Information (Spanish) (PDF) 7/2016
Consents: Medication
Document Number Title Revision Date
TB-411 Disclosure & Consent Drug Therapy TB (English) (DOC) 12/2021
TB-411a Disclosure & Consent Drug Therapy TB (Spanish) (DOC) 12/2021
TB-415 Consent LTBI Therapy (English) (DOC) 12/2021
TB-415a Consent LTBI Therapy (Spanish) (DOC) 12/2021
Control Orders
Document Number Title Revision Date
TB-409 Acknowledgement of Understanding (English) (DOC) 8/2004
TB-409a Acknowledgement of Understanding (Spanish) (DOC) 8/2004
TB-410 Order to Implement and Carry Out Measures for a Client with TB (English) (DOC) 1/2020
TB-410a Order to Implement and Carry Out Measures for a Client with TB (Spanish) (DOC) 1/2020
TB-410b Order to Implement Control Measures for Children with TB (DOC) 1/2020

Case Management

Case Management: Clinical Care
Document Number Title Revision Date
TB-400A Report of Case and Patient Services (PDF) 4/2020
TB-400A-sp Reporte de Caso y Servicios al Cliente (PDF) 5/2021
TB-400B Report of Case and Patient Services (PDF) 4/2020
TB-400B-sp Reporte de Caso y Servicios al Cliente (PDF) 5/2021
TB-201 Case Management Plan for Outpatient Care (DOC) 8/2017
TB-202 TB Initial Health Risk Assessment/History (PDF) 2/2020
TB-202a Evaluación/Historial del riesgo de salud de TB inicial (PDF) 2/2020
TB-203 Education/Counseling Record (DOC) 8/2017
TB-204 Forms/Literature Checklist (DOC) 10/2008
TB-205 Toxicity Assessment (DOC) 8/2017
TB-206 Directly Observed Therapy Log (DOC) 8/2017
TB-209 Hurricane Questionnaire (DOC) 8/2017
TB-231 Bacteriology TB Control (DOC) 8/2017
TB-622 Treatment Record (English) (DOC) 5/2017
TB-220 Referral Form (English) (DOC) 8/2017
TB-220a Referral Form (Spanish) (DOC) 8/2017
TB-619 Registro de Tratamiento (DOC) 8/2017
12-12274 Adverse Drug Reaction (PDF) 8/2017
Resource False Positive Investigation Work Sheet (DOC) 10/2021
Case Management: Drug Resistant TB
Document Number Title Revision Date
TB-700 TB Drug-O-Gram and Clinical Monitoring Overview (English) (DOC) 5/2020
TB-700a TB Drug-O-Gram and Clinical Monitoring Overview (Spanish) (DOC) 5/2020
TB-701 Drug Resistant Tuberculosis Monitoring Check List (English) (DOC) 10/2021
TB-701a Drug Resistant Tuberculosis Monitoring Check List (Spanish) (DOC) 10/2021
TB-702 Toxicity Assessments for Clients on Second-Line Medications (English) (DOC) 10/2021
TB-702a Toxicity Assessments for Clients on Second-Line Medications (Spanish) (DOC) 10/2021
TB-703 TB Bacteriology Monitoring Log (English) (DOC) 4/2020
TB-703a TB Bacteriology Monitoring Log (Spanish) (DOC) 5/2020
TB-704 Tuberculosis Directly Observed Therapy (DOT) Log for Clients on Second-Line Medications (English) (DOC) 4/2020
TB-704a Tuberculosis Directly Observed Therapy (DOT) Log for Clients on Second-Line Medications (Spanish) (DOC) 5/2020
TB-705 Clofazimine Monitoring (English) (DOC) 4/2020
TB-705a Clofazimine Monitoring (Spanish) (DOC) 5/2020
Resource Nursing Guide for Second-Line Tuberculosis Medications (English) (PDF) 12/2021
Resource Peripheral Neuropathy Assessment (English) (PDF) 3/2021
Resource Peripheral Neuropathy Assessment (Spanish) (PDF) 3/2021
Resource Serotonin Syndrome (English) (PDF) 5/2020
Resource Serotonin Syndrome (Spanish) (PDF) 5/2020
Resource Bedaquiline Ordering Process (PDF) 9/2020
Case Management: TB Infection
Document Number Title Revision Date
TB-206a Directly Observed Therapy Log for INH/Rifapentine (DOC) 8/2012
12-14198 3HP Dosing and Symptom Monitoring Log (DOC)
TB-621 Preventive Treatment Record (English) (DOC) 8/2017
TB-620 Registro de Tratamiento Preventivo (DOC) 5/2020
12-14197 Adverse Event Form - 3HP (DOC) 5/2014
Case Management: Video-DOT
Document Number Title Revision Date
12-15760 Mobile Application (English) (PDF) 5/2020
12-15760a Mobile Application (Spanish) (PDF) 5/2020
12-15761 VDOT Mobile Phone User Agreement (English) (DOC) 4/2020
12-15761a VDOT Mobile Phone User Agreement (Spanish) (DOC) 4/2020
12-15762 VDOT Client Participation Agreement (English) (DOC) 4/2020
12-15762a VDOT Client Participation Agreement (Spanish) (DOC) 4/2020
12-15763 Video DOT Medication Layout (English) (PDF) 8/2020
12-15763a Video DOT Medication Layout (Spanish) (PDF) 8/2020
12-15764 VDOT Patient Instructions (English) (DOC) 8/2020
12-15764a VDOT Patient Instructions (Spanish) (DOC) 8/2020
Resource Video-Enabled Directly Observed Therapy, Required and Recommended Activities (English) (PDF) 8/2020
Resource Video-Enabled Directly Observed Therapy, Required and Recommended Activities (Spanish) (PDF) 8/2020

Contact Investigations

Contact Investigations
Document Number Title Revision Date
TB-208 Tuberculosis Contact Screening Form (English) (DOC) 10/2014
TB-208a Tuberculosis Contact Screening Form (Spanish) (DOC) 10/2014
TB-230 Refusal to Complete an Evaluation for TB Infection (PDF) 10/2021
TB-230a Rechazo de completar una evaluación para infección por tuberculosis (PDF) 10/2021
TB-425 TB Infectious Period Calculation Sheet (PDF) 4/2020
TB-425a Hoja de Cálculo del Periodo Infeccioso de la Tuberculosis (PDF) 4/2020
TB-460 TB Contact Investigation Expansion Analysis Check-List (DOC) 11/2007
TB-340 Report of TB Contacts (PDF) 10/2011
TB-340a Informe de Contactos de TB (PDF) 4/2021
TB-341 Continuation of Report of TB Contacts (PDF) 10/2011
TB-341a Continuación de Informe de Contactos de TB (PDF) 4/2021
12-12062 Contact Investigation Worksheet (DOC) 1/2008
12-12104 TB Incident Report (PDF) 9/2019
12-16524 Mass Contact Roster Import Template (XLS) 4/2021
12-16525 Mass Contact Roster Import Data Codebook (DOC) 4/2021

Cohort Review

Cohort Review
Document Number Title Revision Date
12-14064 Cohort Review Presentation Form (PDF) 2/2020
Resource Cohort Review Presentation Form Instructions (PDF) 10/2015
12-14077 Cohort Review Summary Form (XLS) 2/2020
Resource Cohort Review Summary Form Instruction Sheet (PDF) 12/2014
Resource Cohort Review List of Counted Cases (DOC) 10/2019
Resource Cohort Review Infrastructure (PDF) 4/2013

Court Ordered Management

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

Healthcare Personnel

Healthcare Personnel
Document Number Title Revision Date
TB-600 Baseline TB Assessment for HCP (PDF) 3/2020
TB-601 After Hire TB Assessment for HCP (PDF) 3/2020
TB-602 TB Screening Results and Work Clearance for HCP (PDF) 3/2020
TB-603 Tuberculosis (TB) Screening of TB Staff (DOC) 10/2021
TB-604 Report of Tuberculosis Test Conversion in TB Staff (DOC) 10/2021

Correctional Facilities

Correctional Facilities
Document Number Title Revision Date
TB-430 Social History Interview for Correctional Settings (DOC) 6/2018
TB-800 Correctional TB Risk Assessment (PDF) 6/2017
TB-805 Correctional TB Screening Plan (PDF) 1/2022
TB-805-I Correctional TB Screening Plan - Instructions (PDF) 1/2022
TB-810 Tuberculosis Symptoms Screening Form (English) (PDF) 4/2017
TB-810-E Tuberculosis Symptoms Screening Form (Spanish) (PDF) 4/2017
TB-815 Tuberculosis Medical Hold (PDF) 8/2018
12-11461 Positive Reactors/Suspects/Cases (XLS) 12/2021
12-11461 Positive Reactors/Suspects/Cases (PDF)
12/2021
12-11461-I Positive Reactors/Suspects/Cases - Instructions (PDF) 12/2021
12-11462 Monthly Correctional TB Report (PDF) 12/2021
12-11462-I Monthly Correctional TB Report - Instructions (PDF) 12/2021
Resource Summary of Changes for Positive Reactors/Suspects/Cases (PDF) 2/2022
Resource Summary of Changes for Monthly Correctional TB Report (PDF)  2/2022
Resource Prisoner in Transit Medical Summary (PDF) 2/2015
Resource Texas Uniform Health Status Update (PDF) 7/2019
Resource Tubersol Request Form for CH89 Facilities
Video
Resource		 How-to complete the Positive Reactors/Suspects/Cases Form 2/2022
Video
Resource		 How-to complete the Monthly Correctional TB Report 2/2022
Video
Resource		 Correctional and Detention Facilities TB Program in Texas (for Chapter 89 facilities) 2/2022 
Video
Resource		 Correctional and Detention Facilities TB Program in Texas (For Regional and Local Health Departments) 2/2022
Resource Correctional TB Frequently Asked Questions (PDF) 12/2021
Resource DSHS Initial Tuberculosis Screening Algorithm for Incarcerated Individuals (PDF) 12/2021

Targeted Testing

Targeted Testing: General
Document Number Title Revision Date
TB-207 Targeted Tuberculin Testing Screening Form (DOC) 10/2014
TB-501 Adult Tuberculosis (TB) Signs and Symptoms Screening Questionnaire (PDF) 3/2022
Targeted Testing: Children
Document Number Title Revision Date
TB-318 Positive Reactor Worksheet (DOC) 12/2017
12-11494 TB Questionnaire for Children (English) (DOC) 3/2020
12-11494a TB Questionnaire for Children (Spanish) (DOC) 8/2004
Targeted Testing: Congregate Settings
Document Number Title Revision Date
TB-500 TB Risk Assessment Form (PDF) 10/2017
TB-505 Environmental Risk Assessment for Congregate Settings (PDF) 6/2018
12-14427 Congregate Setting Target Testing Monthly Report (DOC) 5/2014
Resource Guidelines for Congregate Setting Target Testing (DOC) 5/2014
Targeted Testing: Tubersol Forms
Document Number Title Revision Date
12-12105 PPD Agreement (DOC) 6/2005
12-12168 Monthly TST (DOC) 10/2015


Last updated April 12, 2022