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    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



  Types of Forms:

    1. Clinical Care
    2. Correctional Facilities
    3. Reporting
    4. Court-Ordered Management (Quarantine)
    5. Cohort Review
    6. Congregate Settings
    7. Phlebotomy Training
    8. User Guides (TX PHIN)  


Medicaid Provider Application ( Adobe PDF File 253 KB)



Clinical Care

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 KB)

TB-203 Education/Counseling Record PDF (110 KB) 
Microsoft Word File (120 KB)
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 Microsoft Word File (83 KB) 10/2014
TB-208 Tuberculosis Contact Screening Form Microsoft Word File (62 KB) 10/2014
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 (33KB)  Microsoft Word File (62 KB)  1/2008
TB-280 Chest Clinic Appointment Card Order From Warehouse    
TB-318 Positive Reactor Worksheet PDF (30 KB)  Microsoft Word File (45 KB) 12/2007
TB-409 Acknowledgement of Understanding (English) Microsoft Word File (40 KB)
TB-409A Reconocimiento de Entendimiento - Disposición de Drogas Antituberculosas Limitadas para Clientes con MTB Microsoft Word File (41 KB)
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 - 3HP Microsoft Word File (42 KB) 7/2014
TB-415c        Disclosure and Consent for Treatment of LTBI - 3HP (Spanish) Microsoft Word File (39 KB) 7/2014
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 Microsoft Word File ( 24 KB)
TB-621 Preventive Treatment Record (English) Call (512) 533-3000  
TB-622 Treatment Record (English) Microsoft Word File (22 KB)
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 (33 KB)
PDF (25 KB)
EF12-12168 Monthly TST Microsoft Word File (51 KB) 10/2015
EF12-12274 Adverse Drug Reaction

Adobe PDF File (77 KB)
Microsoft Word File (45 KB)

EF12-14197 Adverse Event Form - 3HP Microsoft Word File (31 KB) 5/2014
EF12-14198 3HP Dosing and Symptom Monitoring Log Microsoft Word File  (43 KB) 5/2014
12-14685 TB Medical Hold Adobe PDF File (110 KB) 10/2015
L-36 General Consent and Disclosure (English/Spanish)   Adobe PDF File (27 KB) 4/2010

Correctional Facilities

Form Number Form Name Format(s) Revision Date
EF12-11461 Positive Reactors/Suspects/Cases Microsoft Word File (60 KB) 11/2015
EF12-11462 Monthly Correctional TB Report Microsoft Word File (27 KB)
Adobe PDF File (180 KB)
EF12-11462-I Monthly Correctional TB Report - Instructions Adobe PDF File (42 KB) 6/2011
TB-800 Correctional TB Risk Assessment Adobe PDF File (712 KB)
TB-805 Correctional TB Screening Plan Adobe PDF File (366 KB) 3/2017
TB-805-I Correctional TB Screening Plan - Instructions  Adobe PDF File (404 KB) 5/2017 
EF12-12870 TB Symptom Screening Microsoft Word File (40 KB) 9/2014
EF12-12870A TB Symptom Screening (Spanish) Microsoft Word File (41 KB) 7/2014
  Prisoner in Transit Medical Summary Adobe PDF File (52 KB)  
  Texas Uniform Health Status Update Adobe PDF File (49 KB)  


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 Adobe PDF File (461 KB) 6/2017
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
  Guidelines for Congregate Setting Target Testing Microsoft Word File (32 KB) 5/2014
EF12-14427 Congregate Setting Target Testing Monthly Report

Microsoft Word File (136 KB)
MS Excel File (34 KB)



Court Order Management

Form Number


File Size

Health Authority's Affidavit of Medical Evaluation 31 KB


Application for the Extended Management of a Person
with a Communicable Disease

40 KB
Motion for Protective Custody 34 KB
Notification of Probable Cause Hearing

30 KB


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

28 KB  


Order Appointing Special Master 27 KB


Order for Protective Custody 27 KB
Order of Continued Protective Custody and Setting
Hearing on Application
44 KB
Order for Court Reporter to Create Redacted Reporter's Records 29 KB
Order of Transport 28 KB
Waiver of Jury Trial and Right to be Present at Trial 28 KB
Order of Commitment on Application for Extended Management of
Person with Communicable Disease
32 KB


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Cohort Review

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

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Congregate Settings

Form Number Title Format(s) Revision Date


Tuberculosis Risk Assessment Form

Adobe PDF File  (240 KB) 10/2015


Phlebotomy Training

Title Format(s) Revision Date

Phlebotomy Training Informed Consent Form

Microsoft Word File (51 KB)


Continuing Education Contact Hours for Phlebotomy Training

Adobe PDF File (84 KB) 11/2016

Venipuncture Performance Evaluation  

Microsoft Word File (24 KB)  4/2015

DSHS Phlebotomy Class Announcement

Adobe PDF File (298 KB) 10/2016

Tuberculosis Phlebotomy Class Request

Adobe PDF File (1 MB) 10/2016


User Guides

Title Format(s) Revision Date

Texas PHIN User Guide

Adobe PDF File (2 MB) 6/2017

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Last updated June 29, 2017