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    Contact Us

    TB Services Branch

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

    Phone: 512-533-3000
    Fax: 512-533-3167


    Email

TB Forms

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Forms for use in:
Clinics
Correctional Facilities
Reporting
Court-Ordered Management (Quarantine)
Cohort Review

 

Clinic Forms

Form Number Form Name Format(s) Revision Date
TB-201 Case Management Plan for Outpatient Care Adobe PDF File (93 KB)  4/2012
TB-202 Tuberculosis Health Assessment/History

PDF (123 KB) 
Microsoft Word File (58.2 KB)

1/2008
TB-203 Education/Counseling Record PDF (110 KB) 
Microsoft Word File (120 KB)
1/2007
TB-204 Forms/Literature Checklist PDF (62 KB)  Microsoft Word File (132 KB) 10/2008
TB-205 Toxicity Assessment Microsoft Word File (125 KB) 5/2012
TB-206 Directly Observed Therapy Log Microsoft Word File (155 KB) 6/2012
TB-206A Directly Observed Therapy Log for INH/Rifapentine Microsoft Word File (153 KB) 8/2012
TB-207 Targeted Tuberculin Testing Screening Form PDF (81.6 KB)  Microsoft Word File (80.5 KB) 12/2007
TB-208 Tuberculosis Contact Screening Form PDF (69.2 KB)  Microsoft Word File (56 KB) 12/2007
TB-209               Hurricane Questionnaire Microsoft Word File (51 KB) 10/2012
TB-212 Clinical Assessment for Tuberculosis Medication Toxicity:  Isoniazid/Rifapentine Microsoft Word File  (66 KB) 10/2012
TB-220 Referral Form Microsoft Word File (32 KB)  8/2004
TB-231 Bacteriology TB Control PDF (32.7KB) Microsoft Word File (61.5 KB)  1/2008
TB-280 Chest Clinic Appointment Card Order From Warehouse  
TB-318 Positive Reactor Worksheet PDF (29.9 KB)  Microsoft Word File (45 KB) 12/2007
TB-409 Acknowledgement of Understanding (English) Microsoft Word File (40 KB)
8/2004
TB-409A Reconocimiento de Entendimiento - Disposición de Drogas Antituberculosas Limitadas para Clientes con MTB Microsoft Word File (41 KB)
8/2004
TB-410 Order to Implement and Carry Out Measures for a Client with TB Microsoft Word File (34 KB) 8/2004
TB-410A Order to Implement and Carry Out Measures for a Client with TB (Spanish) Microsoft Word File (44 KB) 1/2014
TB-410B Order to Implement Control Measures for Children with Tuberculosis/Orden para implementar medidas de control para niños con tuberculosis Microsoft Word File (33 KB) 8/2004
TB-411 Disclosure & Consent Drug Therapy TB PDF (24 KB)  Microsoft Word File (53 KB) 5/2007
TB-411A Formulario de Declaraciónes y Aceptación a Tratamiento de la Tuberculosis PDF (26 KB)  Microsoft Word File (63 KB) 8/2007
TB-412 Tuberculosis Surveillance Form Order From Warehouse  
TB-415 Consent LTBI Therapy PDF (21 KB)  Microsoft Word File (54 KB) 1/2009
TB-415a Consent LTBI Therapy (Spanish) Microsoft Word File (46 KB) 8/2004
TB-415b Disclosure and Consent for Treatment of LTBI - INH/Rifapentine Microsoft Word File (42 KB) 10/2012
TB-415c        Disclosure and Consent for Treatment of LTBI - INH/Rifapentine (Spanish) Microsoft Word File (53 KB) 1/2014
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) Microsoft Word File (43 KB) 8/2004
EF12-11494A Cuestionario de Tuberculosis Para Niños Microsoft Word File (37 KB) 8/2004
EF12-12062 Contact Investigation Worksheet PDF (72 KB)  Microsoft Word File (171 KB) 1/2008
EF12-12104 TB Incident Report Microsoft Word File (49 KB) 2/2013
EF12-12105 PPD Agreement Microsoft Word File (32.5 KB)
PDF (25.4 KB)
6/2005
EF12-12168 Monthly TST Microsoft Word File (47 KB) 2/2005
EF12-12274 Adverse Drug Reaction

PDF (45.6 KB)
Microsoft Word File (46.5 KB)

6/2011



Correctional Forms

Form Number Form Name Format(s) Revision Date
EF12-11461 Positive Reactors/Suspects/Cases Microsoft Word File (59 KB) 11/2007
EF12-11462 Monthly Correctional TB Report Microsoft Word File (102 KB)
PDF (56 KB)
6/2011 
EF12-11462-I Monthly Correctional TB Report - Instructions PDF (42 KB) 6/2011
EF12-11463 Correctional Tuberculosis Screening Plan

Call (512) 533-3000 

 
TBEF12-12870 Correctional Tuberculosis Program Symptom Screening PDF (17 KB)  Microsoft Word File (45 KB) 1/2008



Reporting Forms

Form Number Title Format(s) Revision Date
TB-340 Report of TB Contacts PDF (121 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 (17 KB) 11/2003
TB-400B Report of Case and Patient Services PDF (18 KB) 11/2003
EF12-11358 Binational Status Report  Microsoft Word File (45 KB) 11/2004
EF12-12104 TB Incident Report Microsoft Word File (49 KB) 3/2011
EF12-12168 Monthly TST Microsoft Word File (47 KB) 11/2005

Court Order Management Forms

Status Number Title Established Revised File Size
Active
Health Authority's Affidavit of Medical Evaluation
 

 

31KB
Active
Application for the Extended Management of a Person with a Communicable Disease
 

--
40KB
Active
Motion for Protective Custody
 

 

34KB
Active
Notification of Probable Cause Hearing
 

 

30KB
Active
Order Appointing Attorney for Inspection, Setting, Hearing and for Notice to Proposed Patient
 

 

28KB
Active
Order Appointing Special Master
 

 

27KB
Active
Order for Protective Custody
 

 

27KB
Active
Order of Continued Protective Custody and Setting Hearing on Application
 

 

44KB
Active
Order for Court Reporter to Create Redacted Reporter's Records
 

 

29KB
Active
Order of Transport
 

 

28KB
Active
Waiver of Jury Trial and Right to be Present at Trial
 

 

28KB
Active
Order of Commitment on Application for Extended Management of Person with Communicable Disease
 

 

32KB



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Cohort Review Forms

Form Number Title Format(s) Revision Date
EF12-14064 Cohort Review Presentation Form Adobe PDF File  (964 KB) 4/2013
  Cohort Review Summary Form Zip (63 KB) 12/2013
EF12-14076 Cohort Review Presentation Form - Instructions Adobe PDF File (65 KB) 5/2013
EF12-14077 Cohort Review Summary Form Instruction Sheet Adobe PDF File (71 KB) 5/2013
  Overview of the Cohort Review Summary Form Adobe PDF File (141 KB) 5/2013
  Cohort Review Infrastructure Form Adobe PDF File (67 KB) 4/2013

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Last updated March 11, 2014
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