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  • Contact Us

    TB and Hansen's Disease Branch

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

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


    Email the TB Program

TB Forms

layout

Types of Forms:

  1. Clinical Care Forms
  2. New Resource Materials
  3. Correctional Facilities
  4. Reporting
  5. Court-Ordered Management (Quarantine)
  6. Cohort Review
  7. Congregate Settings
  8. Phlebotomy Training
  9. Notice of Change in TB Personnel (PDF : 187 kB)
  10. Medicaid Provider Application (PDF : 152 kB)


Clinical Care Forms

Form Number Title Format(s) Revision Date
TB-201 Case Management Plan for Outpatient Care Word 62 kB 8/2017
TB-202 Tuberculosis Health Assessment/History Word 122 kB 8/2017
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-207 Targeted Tuberculin Testing Screening Form Word 162 kB 10/2014
TB-208 Tuberculosis Contact Screening Form Word 142 kB 10/2014
TB-209 Hurricane Questionnaire Word 53 kB 8/2017
TB-220 Referral Form Word 31 kB 8/2017
TB-231 Bacteriology TB Control Word 47 kB 8/2017
TB-318 Positive Reactor Worksheet Word 120 kB 12/2007
L-36 General Consent and Disclosure (English/Spanish) PDF 27 kB 4/2010
TB-409 Acknowledgement of Understanding (English) Word 111 kB 8/2004
TB-409a Reconocimiento de Entendimiento - Disposición de Drogas Antituberculosas Limitadas para Clientes con MTB Word 1,733 kB 8/2004
TB-410 Order to Implement and Carry Out Measures for a Client with TB Word 35 kB 8/2017
TB-410a Order to Implement and Carry Out Measures for a Client with TB (Spanish) Word 35 kB 8/2017
TB-410b Order to Implement Control Measures for Children with Tuberculosis/Orden para implementar medidas de control para niños con tuberculosis Word 29 kB 8/2017
TB-411 Disclosure & Consent Drug Therapy TB Word 119 kB 5/2007
TB-411a Formulario de Declaraciónes y Aceptación a Tratamiento de la Tuberculosis Word 127 kB 8/2007
TB-415 Consent LTBI Therapy Word 118 kB 1/2009
TB-415a Consent LTBI Therapy (Spanish) Word 124 kB 8/2004
TB-415b Disclosure and Consent for Treatment of LTBI - 3HP Word 37 kB 7/2014
TB-415c Disclosure and Consent for Treatment of LTBI - 3HP (Spanish) Word 35 kB 7/2014
TB-425 Tuberculosis Infectious Period Calculation Sheet PDF 485 kB 8/2017 
TB-619 Registro de Tratamiento Word 28 kB 8/2017
TB-620 Registro de Tratamiento Preventivo Word 107 kB 5/2017
TB-621 Preventive Treatment Record (English) Word 23 kB 8/2017
TB-622 Treatment Record (English) Word 121 kB 5/2017
EF12-11494 TB Questionnaire for Children (English) Word 123 kB 8/2004
EF12-11494a Cuestionario de Tuberculosis Para Niños Word 124 kB 8/2004
EF12-12062 Contact Investigation Worksheet Word 223 kB 1/2008
EF12-12104 TB Incident Report PDF 490 kB 8/2017
EF12-12105 PPD Agreement Word 114 kB 6/2005
EF12-12168 Monthly TST Word 130 kB 10/2015
EF12-12274 Adverse Drug Reaction PDF 156 kB 8/2017
EF12-14197 Adverse Event Form - 3HP Word 32 kB 5/2014
EF12-14685 TB Medical Hold PDF 360 kB 10/2015


New Resource Materials

Form Number Title Format(s) Revision Date
False Positive Investigation Work Sheet Word 87 kB 8/2017
Therapeutic Drug Monitoring Process Word 400 kB 8/2017
TB-905 Tuberculin Skin Test Competency Check-List Word 72 kB 8/2017
TB-425 TB Infectious Period Calculation Sheet PDF 485 kB 8/2017
EF12-15017 TB Contact Investigation Expansion Analysis Check-List Word 198 kB 8/2017


Correctional Facilities

Form Number Title Format(s) Revision Date
EF12-11461 Positive Reactors/Suspects/Cases Word 60 kB 11/2015
EF12-11462 Monthly Correctional TB Report Word 27 kB
PDF 180 kB
10/2015
EF12-11462-I Monthly Correctional TB Report - Instructions PDF 42 kB 6/2011
TB-800 Correctional TB Risk Assessment PDF 712 kB
6/2017
TB-805 Correctional TB Screening Plan PDF 366 kB 3/2017
TB-805-I Correctional TB Screening Plan - Instructions PDF 404 kB 5/2017
TB-810 Tuberculosis Symptom Screening Form PDF 118 kB 4/2017
TB-810-E Tuberculosis Symptom Screening Form (Spanish) PDF 115 kB 4/2017
Prisoner in Transit Medical Summary PDF 52 kB
Texas Uniform Health Status Update PDF 49 kB


Reporting

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 461 kB 6/2017
TB-400B Report of Case and Patient Services PDF 18 kB 11/2003
EF12-11358 Binational Status Report Word 45 kB 11/2004
EF12-12168 Monthly TST Word 47 kB 11/2005
Guidelines for Congregate Setting Target Testing Word 32 kB 5/2014
EF12-14427 Congregate Setting Target Testing Monthly Report Word 136 kB
Excel 34 kB
5/2014


Court Order Management

Form Number Title Format(s) Revision Date
86749_1 Health Authority's Affidavit of Medical Evaluation Word 31 kB
86963_1 Application for the Extended Management of a Person with a Communicable Disease Word 40 kB
86964_1 Motion for Protective Custody Word 34 kB
86966_1 Notification of Probable Cause Hearing Word 30 kB
86970_1 Order Appointing Attorney for Inspection, Setting, Hearing and for Notice to Proposed Patient Word 28 kB
86965_1 Order Appointing Special Master Word 27 kB
86968_1 Order for Protective Custody Word 27 kB
86969_1 Order of Continued Protective Custody and Setting Hearing on Application Word 44 kB
86972_1 Order for Court Reporter to Create Redacted Reporter's Records Word 29 kB
84004_1 Order of Transport Word 28 kB
84044_1 Waiver of Jury Trial and Right to be Present at Trial Word 28 kB
84053_1 Order of Commitment on Application for Extended Management of Person with Communicable Disease Word 32 kB


Cohort Review

Form Number Title Format(s) Revision Date
EF12-14064 Cohort Review Presentation Form PDF 4 MB 11/2015
Cohort Review Summary Form Excel 47 kB 11/2015
EF12-14076 Cohort Review Presentation Form - Instructions PDF 114 kB 10/2015
EF12-14077 Cohort Review Summary Form Instruction Sheet PDF 86 kB 12/2014
Cohort Review List of Counted Cases Word 137 kB 11/2015


Congregate Settings

Form Number Title Format(s) Revision Date
EF12-14627 Tuberculosis Risk Assessment Form  PDF 240 kB 10/2015


Phlebotomy Training

Title Format(s) Revision Date
Phlebotomy Training Informed Consent Form Word 51 kB 5/2015
Continuing Education Contact Hours for Phlebotomy Training PDF 101 kB 9/2017
Venipuncture Performance Evaluation Word 24 kB 4/2015
DSHS Phlebotomy Class Announcement PDF 298 kB 10/2016
Tuberculosis Phlebotomy Class Request PDF 1 MB 10/2016


Last updated September 20, 2017