TB Forms Resources

Tuberculosis (TB)

Tuberculosis (TB)

DSHS TB Program

DSHS TB Program

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TB Forms Resources

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Consent/Control Orders

Consents: General

Document NumberTitleRevision Date
L-36General Consent and Disclosure (English/Spanish)3/2025
L-30Authorization to Release Confidential Medical Information (English)7/2016
L-30aAuthorization to Release Confidential Medical Information (Spanish)7/2016

Consents: Medication

Document NumberTitleRevision Date
TB-411Disclosure & Consent Drug Therapy TB (English)9/2024
TB-411aDisclosure & Consent Drug Therapy TB (Spanish)9/2024
TB-415Consent LTBI Therapy (English)3/2025
TB-415aConsent LTBI Therapy (Spanish)12/2021

Control Orders

Document NumberTitleRevision Date
TB-409Acknowledgement of Understanding (English)8/2004
TB-409aAcknowledgement of Understanding (Spanish)8/2004
TB-410Order to Implement and Carry Out Measures for a Client with TB (English)1/2020
TB-410aOrder to Implement and Carry Out Measures for a Client with TB (Spanish)1/2020
TB-410bOrder to Implement Control Measures for Children with TB1/2020

Case Management

Case Management: Clinical Care

Document NumberTitleRevision Date
TB-400AReport of Case and Patient Services (TB-400A)4/2020
TB-400BReport of Case and Patient Services (TB-400B)4/2020
TB-201Tuberculosis Case Management Care Plan (English)9/2024
TB-201ATuberculosis Case Management Care Plan (Spanish)9/2024
TB-202TB Initial Health Risk Assessment/History2/2020
TB-203Education/Counseling Record8/2017
TB-204Tuberculosis Forms/Literature Checklist9/2024
TB-205Toxicity Assessment8/2017
TB-206Directly Observed Therapy Log8/2017
TB-209Hurricane Questionnaire8/2017
TB-220Referral Form (English)8/2017
TB-231Bacteriology TB Control8/2017
TB-240Refusal of Treatment for Latent Tuberculosis Infection (English)3/2024
TB-240ARefusal of Treatment for Latent Tuberculosis Infection (Spanish)3/2024
TB-242Medical Consultation Request Form9/2024
TB-619Registro de Tratamiento8/2017
TB-622Treatment Record (English)5/2017
12-12274Adverse Drug Reaction8/2017
ResourceFalse Positive Investigation Work Sheet10/2021

Case Management: Drug Resistant TB

Document NumberTitleRevision Date
TB-700TB Drug-O-Gram and Clinical Monitoring Overview (English)5/2020
TB-701Drug Resistant Tuberculosis Monitoring Check List (English)10/2021
TB-702Toxicity Assessments for Clients on Second-Line Medications (English)10/2021
TB-703TB Bacteriology Monitoring Log (English)4/2020
TB-704Tuberculosis Directly Observed Therapy (DOT) Log for Clients on Second-Line Medications (English)4/2020
TB-705Clofazimine Monitoring (English)4/2020
TB-706Drug-Resistant Case Conference Presentation Summary4/2023
TB-707Drug-Resistant Case Conference Presentation Outline3/2023
ResourceNursing Guide for Second-Line Tuberculosis Medications (English)11/2024
ResourcePeripheral Neuropathy Assessment (English)3/2021
ResourcePeripheral Neuropathy Assessment (Spanish)3/2021
ResourceSerotonin Syndrome (English)5/2020
ResourceSerotonin Syndrome (Spanish)5/2020
ResourceBedaquiline Ordering Guide10/2024

Case Management: TB Infection

Document NumberTitleRevision Date
TB-206aDirectly Observed Therapy Log for INH/Rifapentine8/2012
12-141983HP Dosing and Symptom Monitoring Log 
TB-621Preventive Treatment Record (English)8/2017
TB-620Registro de Tratamiento Preventivo5/2020
12-14197Adverse Event Form - 3HP5/2014

Case Management: Video-DOT

Document NumberTitleRevision Date
12-15760Mobile Application (English)5/2020
12-15760aMobile Application (Spanish)5/2020
12-15761VDOT Mobile Phone User Agreement (English)4/2020
12-15761aVDOT Mobile Phone User Agreement (Spanish)4/2020
12-15762VDOT Client Participation Agreement (English)4/2020
12-15762aVDOT Client Participation Agreement (Spanish)4/2020
12-15763Video DOT Medication Layout (English)8/2020
12-15763aVideo DOT Medication Layout (Spanish)8/2020
12-15764VDOT Patient Instructions (English)8/2020
12-15764aVDOT Patient Instructions (Spanish)8/2020
ResourceVideo-Enabled Directly Observed Therapy, Required and Recommended Activities (English)8/2020
ResourceVideo-Enabled Directly Observed Therapy, Required and Recommended Activities (Spanish)8/2020

TB Public Health Follow-Up

TB Public Health Follow-Up

Document NumberTitleRevision Date
TB-208Tuberculosis Exposure Screening Form (English)10/2014
TB-230Refusal to Complete an Evaluation for TB Infection10/2021
TB-230aRechazo de completar una evaluación para infección por tuberculosis10/2021
TB-425TB Infectious Period Calculation Sheet4/2020
TB-460TB Public Health Follow-Up Expansion Analysis Check-List11/2007
TB-340Report of People Exposed to TB10/2011
TB-341Continuation Report of people exposed to TB10/2011
12-12062TB Public Health Follow-Up Worksheet1/2008
12-12063Tuberculosis (TB) Corrections Incident Report9/2024
12-12065Do Not Board/Public Health Lookout Consultation Request9/2024
12-12104Tuberculosis (TB) Incident Report9/2024
12-16524Mass Exposure to TB Follow-Up Roster Import Template4/2021
12-16525Mass Exposure to TB Follow-Up Roster Import Data Codebook4/2021

Cohort Review

Cohort Review

Document NumberTitleRevision Date
12-14064Cohort Review Presentation Form6/2025
ResourceCohort Review Presentation Form Instructions6/2025
12-14077Cohort Review Summary Form2/2020
ResourceCohort Review Summary Form Instruction Sheet12/2014
ResourceCohort Review List of Counted Cases2/2025
ResourceCohort Review Infrastructure4/2013

Court Ordered Management

Court Ordered Management

Document NumberTitleRevision Date
84004_1Order of Transport 
84044_1Waiver of Jury Trial and Right to be Present at Trial 
84053_1Order of Commitment on Application for Extended Management of Person with Communicable Disease 
86749_1Health Authority's Affidavit of Medical Evaluation 
86963_1Application for the Extended Management of a Person with a Communicable Disease 
86964_1Motion for Protective Custody 
86965_1Order Appointing Special Master 
86966_1Notification of Probable Cause Hearing 
86968_1Order for Protective Custody 
86969_1Order of Continued Protective Custody and Setting Hearing on Application 
86970_1Order Appointing Attorney for Inspection, Setting, Hearing and for Notice to Proposed Patient 
86972_1Order for Court Reporter to Create Redacted Reporter's Records 

Healthcare Personnel

Healthcare Personnel

Document NumberTitleRevision Date
TB-600Baseline TB Assessment for HCP3/2020
TB-601After Hire TB Assessment for HCP3/2020
TB-602TB Screening Results and Work Clearance for HCP3/2020
TB-603Tuberculosis (TB) Screening of TB Staff10/2021
TB-604Report of Tuberculosis Test Conversion in TB Staff10/2021

Correctional Facilities

Correctional Facilities

Document NumberTitleRevision Date
TB-430Social History Interview for Correctional Settings6/2018
TB-800Correctional TB Risk Assessment6/2017
TB-805Correctional TB Screening Plan7/2025
TB-805ICorrectional TB Screening Plan - Instructions7/2025
TB-805ACorrectional TB Screening Plan - Checklist (for health departments)8/2024
TB-805BCorrectional TB Screening Plan - Checklist (for jails)8/2024
ResourceCorrectional TB Screening Plan - Training9/2024
TB-810Tuberculosis Symptoms Screening Form (English)4/2017
TB-810-ETuberculosis Symptoms Screening Form (Spanish)4/2017
TB-815Tuberculosis Medical Hold8/2018
12-11461Report of TB Conditions1/2023
12-11461Report of TB Conditions1/2023
12-11461-IReport of TB Conditions - Instructions1/2023
12-11462Monthly Correctional TB Report1/2023
12-11462-IMonthly Correctional TB Report - Instructions1/2023
ResourceInformation on Chapter 89-Designated Facilities (PDF)
Information on Chapter 89-Designated Facilities (PPTX)		1/2023
ResourceRevised Monthly Correctional TB Report Forms (PDF)
Revised Monthly Correctional TB Report Forms (PPTX)		1/2023
ResourcePrisoner in Transit Medical Summary2/2015
ResourceTexas Uniform Health Status Update7/2019
ResourceTuberculin Skin Test (TST) Supply Request Form for Chapter 89-Designated Facilities9/2023
ResourceChapter 89-Designated Facilities Tubersol and Syringes Usage Guidance for Local and Regional Health Departments9/2023
ResourceCorrectional TB Frequently Asked Questions1/2023
ResourceCorrectional TB Program Fact Sheet1/2023
ResourceDSHS Initial Tuberculosis Screening Algorithm for Employees and Volunteers6/2023
ResourceDSHS Initial Tuberculosis Screening Algorithm for Incarcerated Individuals6/2023

Targeted Testing

Targeted Testing: General

Document NumberTitleRevision Date
TB-207Targeted Tuberculin Testing Screening Form10/2014
TB-501Adult Tuberculosis (TB) Signs and Symptoms Screening Questionnaire3/2022

Targeted Testing: Children

Document NumberTitleRevision Date
TB-318Positive Reactor Worksheet 12/2017
12-11494TB Questionnaire for Children (English)3/2020
12-11494aTB Questionnaire for Children (Spanish)8/2004

Targeted Testing: Congregate Settings

Document NumberTitleRevision Date
TB-500TB Risk Assessment Form10/2017
TB-505Environmental Risk Assessment for Congregate Settings6/2018
12-14427Congregate Setting Target Testing Monthly Report5/2014
ResourceGuidelines for Congregate Setting Target Testing5/2014