TB Forms Resources

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 4/2020
TB-400B Report of Case and Patient Services 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
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 Process 7/2022

 

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
12-12104 TB Incident Report 9/2019
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

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

 

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

Document Number Title Revision Date
TB-430 Social History Interview for Correctional Settings 6/2018
TB-800 Correctional TB Risk Assessment 6/2017
TB-805 Correctional TB Screening Plan 1/2022
TB-805-I Correctional TB Screening Plan - Instructions 1/2022
TB-810 Tuberculosis Symptoms Screening Form (English) 4/2017
TB-810-E Tuberculosis Symptoms Screening Form (Spanish) 4/2017
TB-815 Tuberculosis Medical Hold 8/2018
12-11461 Report of TB Conditions 1/2023
12-11461 Report of TB Conditions 1/2023
12-11461-I Report of TB Conditions - Instructions 1/2023
12-11462 Monthly Correctional TB Report 1/2023
12-11462-I Monthly Correctional TB Report - Instructions 1/2023
Resource Information on Chapter 89-Designated Facilities
Information on Chapter 89-Designated Facilities
1/2023
Resource Revised Monthly Correctional TB Report Forms
Revised Monthly Correctional TB Report Forms
1/2023
Resource Prisoner in Transit Medical Summary 2/2015
Resource Texas Uniform Health Status Update 7/2019
Resource Tubersol Request Form for CH89 Facilities  
Resource Correctional TB Frequently Asked Questions 1/2023
Resource Correctional TB Program Fact Sheet 1/2023
Resource DSHS Initial Tuberculosis Screening Algorithm for Employees and Volunteers 1/2023
Resource DSHS Initial Tuberculosis Screening Algorithm for Incarcerated Individuals 1/2023

 

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