TB Forms Resources
Quick Links
- Consent/Control Orders
- Case Management
- TB Public Health Follow-Up
- 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) | 4/2010 |
L-30 | Authorization to Release Confidential Medical Information (English) | 7/2016 |
L-30a | Authorization to Release Confidential Medical Information (Spanish) | 7/2016 |
Consents: Medication
Document Number | Title | Revision Date |
---|---|---|
TB-411 | Disclosure & Consent Drug Therapy TB (English) | 12/2021 |
TB-411a | Disclosure & Consent Drug Therapy TB (Spanish) | 12/2021 |
TB-415 | Consent LTBI Therapy (English) | 12/2021 |
TB-415a | Consent LTBI Therapy (Spanish) | 12/2021 |
Control Orders
Document Number | Title | Revision Date |
---|---|---|
TB-409 | Acknowledgement of Understanding (English) | 8/2004 |
TB-409a | Acknowledgement of Understanding (Spanish) | 8/2004 |
TB-410 | Order to Implement and Carry Out Measures for a Client with TB (English) | 1/2020 |
TB-410a | Order to Implement and Carry Out Measures for a Client with TB (Spanish) | 1/2020 |
TB-410b | Order to Implement Control Measures for Children with TB | 1/2020 |
Case Management
Case Management: Clinical Care
Document Number | Title | Revision Date |
---|---|---|
TB-400A | Report of Case and Patient Services (TB-400A) | 4/2020 |
TB-400B | Report of Case and Patient Services (TB-400B) | 4/2020 |
TB-201 | Case Management Plan for Outpatient Care | 8/2017 |
TB-202 | TB Initial Health Risk Assessment/History | 2/2020 |
TB-203 | Education/Counseling Record | 8/2017 |
TB-204 | Forms/Literature Checklist | 10/2008 |
TB-205 | Toxicity Assessment | 8/2017 |
TB-206 | Directly Observed Therapy Log | 8/2017 |
TB-209 | Hurricane Questionnaire | 8/2017 |
TB-231 | Bacteriology TB Control | 8/2017 |
TB-622 | Treatment Record (English) | 5/2017 |
TB-220 | Referral Form (English) | 8/2017 |
TB-619 | Registro de Tratamiento | 8/2017 |
12-12274 | Adverse Drug Reaction | 8/2017 |
Resource | False Positive Investigation Work Sheet | 10/2021 |
Case Management: Drug Resistant TB
Document Number | Title | Revision Date |
---|---|---|
TB-700 | TB Drug-O-Gram and Clinical Monitoring Overview (English) | 5/2020 |
TB-701 | Drug Resistant Tuberculosis Monitoring Check List (English) | 10/2021 |
TB-702 | Toxicity Assessments for Clients on Second-Line Medications (English) | 10/2021 |
TB-703 | TB Bacteriology Monitoring Log (English) | 4/2020 |
TB-704 | Tuberculosis Directly Observed Therapy (DOT) Log for Clients on Second-Line Medications (English) | 4/2020 |
TB-705 | Clofazimine Monitoring (English) | 4/2020 |
TB-706 | Drug-Resistant Case Conference Presentation Summary | 4/2023 |
TB-707 | Drug-Resistant Case Conference Presentation Outline | 3/2023 |
Resource | Nursing Guide for Second-Line Tuberculosis Medications (English) | 12/2021 |
Resource | Peripheral Neuropathy Assessment (English) | 3/2021 |
Resource | Peripheral Neuropathy Assessment (Spanish) | 3/2021 |
Resource | Serotonin Syndrome (English) | 5/2020 |
Resource | Serotonin Syndrome (Spanish) | 5/2020 |
Resource | Bedaquiline Ordering Guide | 9/2023 |
Case Management: TB Infection
Document Number | Title | Revision Date |
---|---|---|
TB-206a | Directly Observed Therapy Log for INH/Rifapentine | 8/2012 |
12-14198 | 3HP Dosing and Symptom Monitoring Log | |
TB-621 | Preventive Treatment Record (English) | 8/2017 |
TB-620 | Registro de Tratamiento Preventivo | 5/2020 |
12-14197 | Adverse Event Form - 3HP | 5/2014 |
Case Management: Video-DOT
Document Number | Title | Revision Date |
---|---|---|
12-15760 | Mobile Application (English) | 5/2020 |
12-15760a | Mobile Application (Spanish) | 5/2020 |
12-15761 | VDOT Mobile Phone User Agreement (English) | 4/2020 |
12-15761a | VDOT Mobile Phone User Agreement (Spanish) | 4/2020 |
12-15762 | VDOT Client Participation Agreement (English) | 4/2020 |
12-15762a | VDOT Client Participation Agreement (Spanish) | 4/2020 |
12-15763 | Video DOT Medication Layout (English) | 8/2020 |
12-15763a | Video DOT Medication Layout (Spanish) | 8/2020 |
12-15764 | VDOT Patient Instructions (English) | 8/2020 |
12-15764a | VDOT Patient Instructions (Spanish) | 8/2020 |
Resource | Video-Enabled Directly Observed Therapy, Required and Recommended Activities (English) | 8/2020 |
Resource | Video-Enabled Directly Observed Therapy, Required and Recommended Activities (Spanish) | 8/2020 |
TB Public Health Follow-Up
TB Public Health Follow-Up
Document Number | Title | Revision Date |
---|---|---|
TB-208 | Tuberculosis Exposure Screening Form (English) | 10/2014 |
TB-230 | Refusal to Complete an Evaluation for TB Infection | 10/2021 |
TB-230a | Rechazo de completar una evaluación para infección por tuberculosis | 10/2021 |
TB-425 | TB Infectious Period Calculation Sheet | 4/2020 |
TB-460 | TB Public Health Follow-Up Expansion Analysis Check-List | 11/2007 |
TB-340 | Report of People Exposed to TB | 10/2011 |
TB-341 | Continuation Report of people exposed to TB | 10/2011 |
12-12062 | TB Public Health Follow-Up Worksheet | 1/2008 |
12-12063 | TB Corrections Incident Report | 9/2024 |
12-12065 | Do Not Board/Public Health Lookout Consultation Request | 9/2024 |
12-12104 | TB Incident Report | 9/2024 |
12-16524 | Mass Exposure to TB Follow-Up Roster Import Template | 4/2021 |
12-16525 | Mass Exposure to TB Follow-Up Roster Import Data Codebook | 4/2021 |
Cohort Review
Cohort Review
Document Number | Title | Revision Date |
---|---|---|
12-14064 | Cohort Review Presentation Form | 2/2020 |
Resource | Cohort Review Presentation Form Instructions | 10/2015 |
12-14077 | Cohort Review Summary Form | 2/2020 |
Resource | Cohort Review Summary Form Instruction Sheet | 12/2014 |
Resource | Cohort Review List of Counted Cases | 10/2019 |
Resource | Cohort Review Infrastructure | 4/2013 |
Court Ordered Management
Court Ordered Management
Healthcare Personnel
Healthcare Personnel
Document Number | Title | Revision Date |
---|---|---|
TB-600 | Baseline TB Assessment for HCP | 3/2020 |
TB-601 | After Hire TB Assessment for HCP | 3/2020 |
TB-602 | TB Screening Results and Work Clearance for HCP | 3/2020 |
TB-603 | Tuberculosis (TB) Screening of TB Staff | 10/2021 |
TB-604 | Report of Tuberculosis Test Conversion in TB Staff | 10/2021 |
Correctional Facilities
Correctional Facilities
Targeted Testing
Targeted Testing: General
Document Number | Title | Revision Date |
---|---|---|
TB-207 | Targeted Tuberculin Testing Screening Form | 10/2014 |
TB-501 | Adult Tuberculosis (TB) Signs and Symptoms Screening Questionnaire | 3/2022 |
Targeted Testing: Children
Document Number | Title | Revision Date |
---|---|---|
TB-318 | Positive Reactor Worksheet | 12/2017 |
12-11494 | TB Questionnaire for Children (English) | 3/2020 |
12-11494a | TB Questionnaire for Children (Spanish) | 8/2004 |
Targeted Testing: Congregate Settings
Document Number | Title | Revision Date |
---|---|---|
TB-500 | TB Risk Assessment Form | 10/2017 |
TB-505 | Environmental Risk Assessment for Congregate Settings | 6/2018 |
12-14427 | Congregate Setting Target Testing Monthly Report | 5/2014 |
Resource | Guidelines for Congregate Setting Target Testing | 5/2014 |