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  • DSHS TB and Hansen's Disease Branch
    Post Office Box 149347, MC 1873
    Austin, TX 78714

    Phone: 737-255-4300
    Fax: 512-989-4010

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TB Forms Resources


Consent/Control Orders Case Management Contact Investigations 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) (PDF) 4/2010
L-30 Authorization to Release Confidential Medical Information (English) (PDF) 7/2016
L-30a Authorization to Release Confidential Medical Information (Spanish) (PDF) 7/2016
Consents: Medication
Document Number Title Revision Date
TB-411 Disclosure & Consent Drug Therapy TB (English) (DOC) 12/2021
TB-411a Disclosure & Consent Drug Therapy TB (Spanish) (DOC) 12/2021
TB-415 Consent LTBI Therapy (English) (DOC) 12/2021
TB-415a Consent LTBI Therapy (Spanish) (DOC) 12/2021
Control Orders
Document Number Title Revision Date
TB-409 Acknowledgement of Understanding (English) (DOC) 8/2004
TB-409a Acknowledgement of Understanding (Spanish) (DOC) 8/2004
TB-410 Order to Implement and Carry Out Measures for a Client with TB (English) (DOC) 1/2020
TB-410a Order to Implement and Carry Out Measures for a Client with TB (Spanish) (DOC) 1/2020
TB-410b Order to Implement Control Measures for Children with TB (DOC) 1/2020

Case Management

Case Management: Clinical Care
Document Number Title Revision Date
TB-400A Report of Case and Patient Services (PDF) 4/2020
TB-400A-sp Reporte de Caso y Servicios al Cliente (PDF) 5/2021
TB-400B Report of Case and Patient Services (PDF) 4/2020
TB-400B-sp Reporte de Caso y Servicios al Cliente (PDF) 5/2021
TB-201 Case Management Plan for Outpatient Care (DOC) 8/2017
TB-202 TB Initial Health Risk Assessment/History (PDF) 2/2020
TB-202a Evaluación/Historial del riesgo de salud de TB inicial (PDF) 2/2020
TB-203 Education/Counseling Record (DOC) 8/2017
TB-204 Forms/Literature Checklist (DOC) 10/2008
TB-205 Toxicity Assessment (DOC) 8/2017
TB-206 Directly Observed Therapy Log (DOC) 8/2017
TB-209 Hurricane Questionnaire (DOC) 8/2017
TB-231 Bacteriology TB Control (DOC) 8/2017
TB-622 Treatment Record (English) (DOC) 5/2017
TB-220 Referral Form (English) (DOC) 8/2017
TB-220a Referral Form (Spanish) (DOC) 8/2017
TB-619 Registro de Tratamiento (DOC) 8/2017
12-12274 Adverse Drug Reaction (PDF) 8/2017
Resource False Positive Investigation Work Sheet (DOC) 10/2021
Case Management: Drug Resistant TB
Document Number Title Revision Date
TB-700 TB Drug-O-Gram and Clinical Monitoring Overview (English) (DOC) 5/2020
TB-700a TB Drug-O-Gram and Clinical Monitoring Overview (Spanish) (DOC) 5/2020
TB-701 Drug Resistant Tuberculosis Monitoring Check List (English) (DOC) 10/2021
TB-701a Drug Resistant Tuberculosis Monitoring Check List (Spanish) (DOC) 10/2021
TB-702 Toxicity Assessments for Clients on Second-Line Medications (English) (DOC) 10/2021
TB-702a Toxicity Assessments for Clients on Second-Line Medications (Spanish) (DOC) 10/2021
TB-703 TB Bacteriology Monitoring Log (English) (DOC) 4/2020
TB-703a TB Bacteriology Monitoring Log (Spanish) (DOC) 5/2020
TB-704 Tuberculosis Directly Observed Therapy (DOT) Log for Clients on Second-Line Medications (English) (DOC) 4/2020
TB-704a Tuberculosis Directly Observed Therapy (DOT) Log for Clients on Second-Line Medications (Spanish) (DOC) 5/2020
TB-705 Clofazimine Monitoring (English) (DOC) 4/2020
TB-705a Clofazimine Monitoring (Spanish) (DOC) 5/2020
Resource Nursing Guide for Second-Line Tuberculosis Medications (English) (PDF) 12/2021
Resource Peripheral Neuropathy Assessment (English) (PDF) 3/2021
Resource Peripheral Neuropathy Assessment (Spanish) (PDF) 3/2021
Resource Serotonin Syndrome (English) (PDF) 5/2020
Resource Serotonin Syndrome (Spanish) (PDF) 5/2020
Resource Bedaquiline Ordering Process (PDF) 9/2020
Case Management: TB Infection
Document Number Title Revision Date
TB-206a Directly Observed Therapy Log for INH/Rifapentine (DOC) 8/2012
12-14198 3HP Dosing and Symptom Monitoring Log (DOC)
TB-621 Preventive Treatment Record (English) (DOC) 8/2017
TB-620 Registro de Tratamiento Preventivo (DOC) 5/2020
12-14197 Adverse Event Form - 3HP (DOC) 5/2014
Case Management: Video-DOT
Document Number Title Revision Date
12-15760 Mobile Application (English) (PDF) 5/2020
12-15760a Mobile Application (Spanish) (PDF) 5/2020
12-15761 VDOT Mobile Phone User Agreement (English) (DOC) 4/2020
12-15761a VDOT Mobile Phone User Agreement (Spanish) (DOC) 4/2020
12-15762 VDOT Client Participation Agreement (English) (DOC) 4/2020
12-15762a VDOT Client Participation Agreement (Spanish) (DOC) 4/2020
12-15763 Video DOT Medication Layout (English) (PDF) 8/2020
12-15763a Video DOT Medication Layout (Spanish) (PDF) 8/2020
12-15764 VDOT Patient Instructions (English) (DOC) 8/2020
12-15764a VDOT Patient Instructions (Spanish) (DOC) 8/2020
Resource Video-Enabled Directly Observed Therapy, Required and Recommended Activities (English) (PDF) 8/2020
Resource Video-Enabled Directly Observed Therapy, Required and Recommended Activities (Spanish) (PDF) 8/2020

Contact Investigations

Contact Investigations
Document Number Title Revision Date
TB-208 Tuberculosis Contact Screening Form (English) (DOC) 10/2014
TB-208a Tuberculosis Contact Screening Form (Spanish) (DOC) 10/2014
TB-230 Refusal to Complete an Evaluation for TB Infection (PDF) 10/2021
TB-230a Rechazo de completar una evaluación para infección por tuberculosis (PDF) 10/2021
TB-425 TB Infectious Period Calculation Sheet (PDF) 4/2020
TB-425a Hoja de Cálculo del Periodo Infeccioso de la Tuberculosis (PDF) 4/2020
TB-460 TB Contact Investigation Expansion Analysis Check-List (DOC) 11/2007
TB-340 Report of TB Contacts (PDF) 10/2011
TB-340a Informe de Contactos de TB (PDF) 4/2021
TB-341 Continuation of Report of TB Contacts (PDF) 10/2011
TB-341a Continuación de Informe de Contactos de TB (PDF) 4/2021
12-12062 Contact Investigation Worksheet (DOC) 1/2008
12-12104 TB Incident Report (PDF) 9/2019
12-16524 Mass Contact Roster Import Template (XLS) 4/2021
12-16525 Mass Contact Roster Import Data Codebook (DOC) 4/2021

Cohort Review

Cohort Review
Document Number Title Revision Date
12-14064 Cohort Review Presentation Form (PDF) 2/2020
Resource Cohort Review Presentation Form Instructions (PDF) 10/2015
12-14077 Cohort Review Summary Form (XLS) 2/2020
Resource Cohort Review Summary Form Instruction Sheet (PDF) 12/2014
Resource Cohort Review List of Counted Cases (DOC) 10/2019
Resource Cohort Review Infrastructure (PDF) 4/2013

Court Ordered Management

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

Healthcare Personnel

Healthcare Personnel
Document Number Title Revision Date
TB-600 Baseline TB Assessment for HCP (PDF) 3/2020
TB-601 After Hire TB Assessment for HCP (PDF) 3/2020
TB-602 TB Screening Results and Work Clearance for HCP (PDF) 3/2020
TB-603 Tuberculosis (TB) Screening of TB Staff (DOC) 10/2021
TB-604 Report of Tuberculosis Test Conversion in TB Staff (DOC) 10/2021

Correctional Facilities

Correctional Facilities
Document Number Title Revision Date
TB-430 Social History Interview for Correctional Settings (DOC) 6/2018
TB-800 Correctional TB Risk Assessment (PDF) 6/2017
TB-805 Correctional TB Screening Plan (PDF) 1/2022
TB-805-I Correctional TB Screening Plan - Instructions (PDF) 1/2022
TB-810 Tuberculosis Symptoms Screening Form (English) (PDF) 4/2017
TB-810-E Tuberculosis Symptoms Screening Form (Spanish) (PDF) 4/2017
TB-815 Tuberculosis Medical Hold (PDF) 8/2018
12-11461 Positive Reactors/Suspects/Cases (XLS) 12/2021
12-11461 Positive Reactors/Suspects/Cases (PDF)
12/2021
12-11461-I Positive Reactors/Suspects/Cases - Instructions (PDF) 12/2021
12-11462 Monthly Correctional TB Report (PDF) 12/2021
12-11462-I Monthly Correctional TB Report - Instructions (PDF) 12/2021
Resource Summary of Changes for Positive Reactors/Suspects/Cases (PDF) 2/2022
Resource Summary of Changes for Monthly Correctional TB Report (PDF)  2/2022
Resource Prisoner in Transit Medical Summary (PDF) 2/2015
Resource Texas Uniform Health Status Update (PDF) 7/2019
Resource Tubersol Request Form for CH89 Facilities
Video
Resource		 How-to complete the Positive Reactors/Suspects/Cases Form 2/2022
Video
Resource		 How-to complete the Monthly Correctional TB Report 2/2022
Video
Resource		 Correctional and Detention Facilities TB Program in Texas (for Chapter 89 facilities) 2/2022 
Video
Resource		 Correctional and Detention Facilities TB Program in Texas (For Regional and Local Health Departments) 2/2022
Resource Correctional TB Frequently Asked Questions (PDF) 12/2021
Resource DSHS Initial Tuberculosis Screening Algorithm for Incarcerated Individuals (PDF) 12/2021

Targeted Testing

Targeted Testing: General
Document Number Title Revision Date
TB-207 Targeted Tuberculin Testing Screening Form (DOC) 10/2014
TB-501 Adult Tuberculosis (TB) Signs and Symptoms Screening Questionnaire (PDF) 3/2022
Targeted Testing: Children
Document Number Title Revision Date
TB-318 Positive Reactor Worksheet (DOC) 12/2017
12-11494 TB Questionnaire for Children (English) (DOC) 3/2020
12-11494a TB Questionnaire for Children (Spanish) (DOC) 8/2004
Targeted Testing: Congregate Settings
Document Number Title Revision Date
TB-500 TB Risk Assessment Form (PDF) 10/2017
TB-505 Environmental Risk Assessment for Congregate Settings (PDF) 6/2018
12-14427 Congregate Setting Target Testing Monthly Report (DOC) 5/2014
Resource Guidelines for Congregate Setting Target Testing (DOC) 5/2014


Last updated May 20, 2022