Forms For Local Health Departments

All individuals who are reported to the health department as a presumed or confirmed case of active TB disease, regardless of the source of care, should have a permanent VDH medical record.  The Recommendations for TB Record and Form Use should be referenced when using the documents found on this page.

The TB Nurse Case Management Clinical Pathway provides a sequential list of tasks, decisions, and interventions performed during the care of a presumptive or confirmed TB case.  This tool has been developed for TB nurse case managers to use during the management of their patients.  The clinical pathway was updated in April 2019.

Slides for the April 3rd, 2019 TB Materials release session: TB Materials Training

Chart Organization

Active TB Chart Organization 03-2019
TB Infection Chart Organization 03-2019

Chart Review

Active TB Chart Review Tool 03-2019
TB Infection Chart Review Tool 03-2019

Clip 1 - Registration and Consents

Clip 1 Isolation Instructions 03-2019
Clip 1 DOT Agreement 03-2019
Clip 1 VET Agreement 2018 03-2019
Clip 1 Case Closure Form
Clip 1 RVCT (Report of Verified Case of Tuberculosis)
Completing the Report of Verified Case of Tuberculosis using TB Chart Forms 03-2019

Clip 2 - Medications

VDH Summary of Providers of Care '13
Clip 2 Medication List 03-2019
Clip 2 DOT Log 03-2019
Clip 2 DOT Log for 12 Dose 3HP 03-2019

Clip 3 - Assessment

Clip 3 Active TB Case Summary 03-2019
Clip 3 Monthly Clinical Assessment 03-2019
Clip 3 TB & Newcomer Health History 03-2019
Clip 3 TB Risk Assessment 512 Form
512 Instructions
Clip 3 Contact Registration Form

Clip 4 - Notes

Clip 4 Progress Notes
Clip 4 Clinician Orders & Progress Notes 03-2019

Clip 5 - Lab Specimens

Clip 5 Bacteriology Flow Sheet 03-2019
Clip 5 Lab Flow Sheet 03-2019
Clip 5 Vision Monitoring 03-2019
Clip 5 Hearing Monitoring 03-2019

Clip 6 - External

Interjurisdictional Notification Form
Interjurisdictional Follow-Up Form
International Tuberculosis Notification Form
VDH - HIPAA - Authorization for Disclosure of PHI
TB Hospital Discharge Plan