Tuberculosis Section

Public Health Clinic Forms

Form Number Form Description Rev Date
     
Reporting & Notification
3140 New TB Suspect Referral PDF 12/2011
3141 Initial Report on Patient with TB PDF 12/2011
3142 Follow-up Report on Patient with TB PDF 12/2011
NTCA 3-2002 Interjurisdictional Tuberculosis Notification
Instructions PDF
Notification Form PDF
Follow-up Form PDF
03/2002
03/2002
05/2002
CDC72.9A Report of Verified Case of Tuberculosis (RVCT) – print pp. 1-3
Follow-up Report 1 – print p. 4
Follow-up Report 2 –  print pp.5-6		 09/2008
Legal
3144 Active Tuberculosis (TB) Treatment Plan [English, Bhutanese, Burmese, Chinese, Farsi, Korean, Nepali, Spanish, Vietnamese] PDF 12/2011
DPH04/328HW Medication Information [English, Bhutanese, Burmese, Chinese, Farsi, Korean, Nepali, Spanish, Vietnamese] PDF 12/2011
3575 Refusal of Care Form - TB Program [English, Bhutanese, Burmese, Chinese, Farsi, Korean, Nepali, Spanish, Vietnamese] PDF 12/2011
3609.LTBI Consent and Treatment Plan – Latent TB Infection (LTBI) [English, Bhutanese, Burmese, Chinese, Farsi, Korean, Nepali, Spanish, Vietnamese] PDF 12/2011
3609.TB Consent to Treatment – Active TB Case/Suspect [English, Bhutanese, Burmese, Chinese, Farsi, Korean, Nepali, Spanish, Vietnamese] PDF 12/2011
603.DOT Directly Observed Therapy (DOT) Agreement for TB Treatment [English, Bhutanese, Burmese, Chinese, Farsi, Korean, Nepali, Spanish, Vietnamese] PDF 12/2011
Case Management/Clinic
3121-R Tuberculosis Services PDF 12/2011
3126 Contact Investigation Report PDF 12/2011
3130 DOT Medication Sheet PDF 12/2011
INH-RPT Isoniazid/Rifapentine Reporting & DOT PDF 10/2012
INST Instructions for INH/RPT Reporting form PDF 10/2012
3135 Tuberculosis Flowsheet PDF 12/2011
TB/HIV TB/HIV Flowsheet PDF 12/2011
DPH 04/324 MDR-TB Flowsheet PDF 12/2011
2nd Line Second Line Therapy Authorization Form PDF 12/2011
HAIN HAIN Rapid TB Diagnostic & Resistance Submission Form PDF 12/2011
3143 Bacteriologic Examinations Record PDF 12/2011
3412-HD Georgia Public Health Laboratory - TB Submission Form PDF 12/2011
  Case Review Format PDF 12/2011
  12 point of Tuberculosis (TB) Patient Education PDF 04/2012
  Tuberculosis Education Record PDF 04/2012
  Scaled Goal Matrix Tool PDF   
  Case Management Timeline PDF   
  Client Referral Form PDF 10/2011
  TB Worksheet - Class B1/B2 aliens PDF