| Form Number |
Form Name |
Format(s) |
Revision Date |
| TB-201 |
Case Management Plan for Outpatient Care |
PDF (77.8 KB)
DOC (92 KB) |
January, 2006 |
| TB-202 |
Tuberculosis Health Assessment/History |
DOC (68 KB) |
February, 2005 |
| TB-203 |
Education/Counseling Record |
DOC (81 KB) |
August, 2004 |
| TB-204 |
Forms/Literature Checklist |
DOC (63 KB) |
August, 2004 |
| TB-205 |
Toxicity Assessment |
DOC (130 KB) |
August, 2004 |
| TB-206 |
Direct Observed Therapy Log |
DOC (200 KB) |
November, 2007 |
| TB-207 |
Targeted Tuberculin Testing Screening Form |
DOC (65 KB) |
August, 2004 |
| TB-220 |
Referral Form |
DOC (32 KB) |
August, 2004 |
| TB-231 |
Bacteriology TB Control |
DOC (48 KB) |
August, 2004 |
| TB-280 |
Chest Clinic Appointment Card |
Order From Warehouse |
|
| TB-318 |
Positive Reactor Worksheet |
DOC (39 KB) |
August, 2004 |
| TB-409 |
Acknowledgement of Understanding (English) |
DOC (40 KB)
|
August, 2004 |
| TB-409A |
Reconocimiento de Entendimiento - Disposición de Drogas Antituberculosas Limitadas para Clientes con MTB |
DOC (41 KB)
|
August, 2004 |
| TB-410 |
Order to Implement and Carry Out Measures for a Client with TB |
DOC (34 KB) |
August, 2004 |
| TB-410A |
Orden para Implementar y Llevar a Cabo Medidas Para un Paciente con Tuberculosis |
DOC (38 KB) |
August, 2004 |
| TB-410B |
Order to Implement Control Measures for Children with Tuberculosis/Orden para implementar
medidas de control para niños con tuberculosis |
DOC (33 KB) |
August, 2004 |
| TB-411 |
Disclosure & Consent Drug Therapy TB |
DOC (42 KB) |
August, 2004 |
| TB-411A |
Formulario de Declaraciónes y Aceptación a Tratamiento de la Tuberculosis |
DOC (52 KB) |
August, 2004 |
| TB-412 |
Tuberculosis Surveillance Form |
Order From Warehouse |
|
| TB-415 |
Consent LTBI Therapy |
DOC (39 KB) |
August, 2004 |
| TB-415a |
Consent LTBI Therapy |
DOC (46 KB) |
August, 2004 |
| TB-617 |
Preventive Treatment Record (Vietnamese) |
Call (512)458-7447 |
|
| TB-618 |
Treatment Record (Vietnamese) |
Call (512)458-7447 |
|
| TB-619 |
Registro de Tratamiento |
Call (512)458-7447 |
|
| TB-620 |
Registro de Tratamiento Preventivo |
Call (512)458-7447 |
|
| TB-621 |
Preventive Treatment Record (English) |
Call (512)458-7447 |
|
| TB-622 |
Treatment Record (English) |
Call (512)458-7447 |
|
| EF12-11494 |
TB Questionnaire (English) |
DOC (43 KB) |
August, 2004 |
| EF12-11494A |
Cuestionario de Tuberculosis |
DOC (37 KB) |
August, 2004 |
| EF12-12104 |
TB Incident Report |
DOC (49 KB) |
February, 2005 |
| EF12-12105 |
PPD Agreement |
DOC (32.5 KB)
PDF (25.4 KB) |
June, 2005 |
| EF12-12168 |
Monthly TST |
DOC (47 KB) |
February, 2005 |
| EF12-12274 |
Adverse Drug Reaction |
PDF (30.1 KB) |
September, 2005 |
| EF12-12478 |
Genotyping Request Form |
PDF (18.2 KB) |
July, 2006
|
| Form Number |
Form Name |
Format(s) |
Revision Date |
| EF12-11461 |
Positive Reactors/Suspects/Cases |
DOC (59 KB) |
November, 2007 |
| EF12-11462 |
Monthly Correctional TB Report |
DOC (69 KB) |
November, 2007 |
| EF12-11463 |
Correctional Tuberculosis Screening Plan |
DOC (75.5 KB) |
August, 2007 |
| Form Number |
Title |
Format(s) |
Revision Date |
| TB-340 |
Report of TB Contacts |
PDF (33 KB) |
January, 2003 |
| TB-341 |
Continuation of Report of TB Contacts |
PDF (26 KB) |
January, 2003 |
| TB-400A |
Report of Case and Patient Services |
PDF (17 KB) |
November, 2003 |
| TB-400B |
Report of Case and Patient Services |
PDF (18 KB) |
November, 2003 |
| EF12-11358 |
Binational Status Report |
DOC (45 KB) |
August, 2004 |
| EF12-12104 |
TB Incident Report |
DOC (49 KB) |
February, 2005 |
| EF12-12168 |
Monthly TST |
DOC (47 KB) |
February, 2005 |
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