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Forms Summary


For Physicians and Medical Facilities:

This collection of forms is intended for use by physicians and medical facilities to communicate with the health director in accordance with the TB Control Laws outlined in the Code of Virginia and with reporting requirements set by the State Board of Health. All letters should be printed or typed on appropriate letterhead. A brief description and appropriate usage of each form is detailed below.

Form Name and Description and Usage of the Form

Negative Diagnosis Form (2001A-TB-000)
This form is to be completed and submitted to the local health director by the examining physician who makes a diagnosis other than active TB disease for a patient under an examination request.

Initial TB Report (EPI-1)
The initial TB report to the local health director is to be completed by the examining or treating physician or head of a medical facility providing inpatient or outpatient diagnosis or treatment when there are reasonable grounds to believe that a person has active TB disease.

Secondary TB Report (2001A-TB-002)
The secondary TB report to the local health director is to be completed by the examining or treating physician or head of a medical facility providing inpatient or outpatient diagnosis or treatment. This form is to be completed simultaneously with or immediately following the initial report.

Subsequent TB Reports (2013A-TB-003)
The subsequent TB report is to be completed when there has been a change in a patient's treatment regimen, if there is suspicion of treatment failure, when ceasing treatment for active TB disease, and/or when there are any other updates on the patient's case.

TB Treatment/Discharge Plan Template (2005A-TB-004)
This template is to be used by the treating physician or head of a medical facility providing inpatient or outpatient treatment for active TB disease to capture information which may be either requested or required by the local health director. This template may also be used to develop a patient's Discharge Plan, which must be submitted to and approved by the local health director prior to discharge.

TB Notice of Discharge Letter (2001A-TB-005)
[MS Word] This form is to be used by the treating physician or head of a medical facility to communicate to the local health director that a patient with active TB disease -- who was not hospitalized for his/her TB -- is to be discharged from the hospital.

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For Health Directors

These forms are intended for use by the local health director and the Commissioner to communicate with individual patients, physicians, and medical facilities in accordance with the TB Control Laws outlined in the Code of Virginia and with reporting requirements set by the State Board of Health. All letters should be printed or typed on appropriate letterhead. A brief description and appropriate usage of each form is detailed below.

Form Letters to Patients:

Form Name Description and Usage of the Form

Examination Request Letter
Used by the local health director, the Commissioner, or the Commissioner's designee to communicate an examination request to an individual who has or is suspected of having active TB disease. This form can be used either for the initial exam or to request that the patient have a more thorough examination for active TB disease.

Counseling Order Letter
Used by the local health director, the Commissioner, or the Commissioner's designee to issue a counseling order to an individual who has active TB disease, is believed to know that he/she is infected, and who is engaging in at-risk behavior.

Outpatient Treatment Order Letter
Used by the local health director, the Commissioner, or the Commissioner's designee to issue an outpatient treatment order to an individual who has active TB disease and who is either unable or unwilling to adhere to his/her prescribed treatment regimen.

Emergency Detention Order
Used by the Commissioner to issue an emergency detention order to an individual who has active TB disease, is engaging in at-risk behavior, and poses an imminent threat to the health of others.

Form Letters to Physicians and Medical Facilities Form Name Description and Usage of the Form

Guidance on Filing an Initial Report
Used by the local health director to communicate reporting requirements to physicians and medical facilities who have failed to file an initial report.

Guidance on Filing a Secondary Report
[MS Word] Used by the local health director to communicate reporting requirements to physicians and medical facilities who have failed to file a secondary report.

Guidance on Filing Subsequent Reports
[MS Word] Used by the local health director to communicate reporting requirements to physicians and medical facilities who have failed to file subsequent reports.

Guidance on Updating or Notifying of Cessation of Treatment
[MS Word] Used by the local health director to communicate reporting requirements to physicians and medical facilities who have failed to make appropriate updates or to notify of cessation of treatment.

Guidance on Filing Laboratory Results
[MS Word] Used by the local health director to communicate reporting requirements to laboratories and medical facilities who have failed to file laboratory results.

Guidance on Filing Notice of Discharge
[MS Word] Used by the local health director to communicate reporting requirements to physicians and medical facilities who have failed to file a notice of discharge.

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Last Updated: 03-19-2014

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