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Tuberculosis Forms

Diagnosis/Assessment Forms | TB Medication and Side Effect Surveillance Forms | Case Management/DOT Forms | Contact Investigation Forms | Isolation Form | Transfer Notification Forms | Glossary


Diagnosis/Assessment Forms

Confirmed/Suspected Report of Tuberculosis Disease (MT)
TB Diagnostic Referral Form (MT)
Bacteriology Data Sheet (MT)
Biochemistry Data (MT)
TB Home Evaluation (MT)
Address Information Request (OR)

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TB Medication and Side Effect Surveillance Forms
*The current Idaho Tuberculosis Drug Assistance Program Order Form (NOT included in the PDF file) can be obtained by calling the Office of Epidemiology, Food Protection, and Immunizations (208) 334-5939.

See also the Bacteriology Data Sheet and Biochemistry Data Forms.
Panhandle Health District's TB Drug Interview Sheet (ID)
Adverse Reactions & Side Effects to TB Medications (MT)
Visual Acuity and Ishihara's Tests for Color Blindness - Test Results (OR)
Treatment of Active TB Education Form (MT)
Treatment of LTBI Education Form (MT)
Usual Length of TB Treatment Plan - visually depicted (OR)
Tuberculosis Treatment Agreement - English (WA)
Tuberculosis Treatment Agreement - Spanish (WA)

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Case Management/DOT Forms

Case Management Treatment Plan for Active TB Disease
TB Disease Monthly Patient Assessment (MT)
Monthly Tuberculosis Case Report (MT)
LTBI Monthly Patient Assessment (MT)
TB Case Management Monitoring Record (OR)
Critical Pathway (WA)
Tuberculosis Treatment Record DOT (MT)
Tuberculosis DOT Agreement (MT)
DOT Record (ID)

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Contact Investigation Forms

Idaho TB Contact Tracing Form
TB Contact Investigation Report (MT)
Tuberculosis Contact Investigation Form (WA)
TB Contact Investigation Summary (MT)

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Isolation Forms

Home Isolation Agreement (MT)
Home Isolation Agreement (OR)
Isolation Instructions - Engligh (WA)
Isolation Instructions - Spanish (WA)
Voluntary Isolation/Quarantine Agreement - English (WA)
Voluntary Isolation/Quarantine Agreement - Spanish (WA)
Orders to Voluntarily Comply with TB Control Measures (OR)

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Transfer Notification Forms

Interjurisdictional TB Protocols
 (NTCA)
Interjurisdictional TB Notification (NTCA)
Interjurisdictional Follow-up Form (NTCA)

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Glossary
 

ID = Idaho
MT = Montana
NTCA = National TB Controllers Association

OR = Oregon
WA = Washington State

Other definitions:

Abbreviation List
Glossary (From TB Manual)







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