Forms for Local Health Departments

Chart (New)

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 August 2021.

Please review VDH TB Program Reporting Guidance for information on how to report new confirmed/presumptive active TB cases, LTBI cases, and information on contact investigations. An infographic illustrating the reporting flow is also available here: VDH TB Reporting Guidance Visual.

Please use this form and email/fax cover letter to conduct initial or follow-up outreach to community providers regarding cases of LTBI. Once completed, you may create or update the investigation in VEDSS directly, or you may send it to Central Office for VEDSS entry.

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

A summary of changes to the Monthly TB Clinical Assessment Form, now titled Initial/Monthly Clinical Assessment Form: Changes to the Monthly TB Clinical Assessment Form - 09/2019

Chart Organization

Active TB Chart Organization - 03/2019
TB Infection Chart Organization - 09/2019

Chart Review

Active TB Chart Review Tool - 03/2019
TB Infection Chart Review Tool - 09/2019

Clips

Clip 1 - Registration and Consents

Clip 1 Isolation Instructions - 03/2019 | Amharic | Korean | Spanish | Tagalog | Vietnamese
Clip 1 DOT Agreement - 03/2019  | Amharic | Korean | Spanish | Tagalog | Vietnamese
Clip 1 VET Agreement - 03/2020 | Amharic | Korean | Spanish | Tagalog | Vietnamese
Clip 1 TB Case Completion/Discontinue Report & Worksheet (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 Initial/Monthly Clinical Assessment - 10/2019
Clip 3 Active TB Case Summary - 03/2019
Clip 3 TB & Newcomer Health History - 08/2021
Clip 3 TB Risk Assessment-512 and Instructions - 11/2021
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 (IJN) Forms:

• IJN Form for Active/Possible TB Disease
• IJN Form for TB Contacts
• IJN Form for TB Infection (LTBI)

International Notification Form (CureTB) for cases
International Notification Form (CureTB) for contacts/source
VDH - HIPAA - Authorization for Disclosure of PHI
TB Hospital Discharge Plan | Amharic | Korean | Spanish | Tagalog | Vietnamese

Contact Investigation

Contact Investigation Documentation Instructions

• Link to Initial 502 Electronic Submission Form
• Final 502 (Fillable)
• Excel Version of Final 502 Form
• Summary Report of a TB Contact Investigation in a Congregate Setting

Contact Registration Form
Global TB Institute Video: Effective Interviewing for Tuberculosis Contact Investigation
CDC Intro to TB slide set - can be adapted and used for education during contact investigations

Alternative Housing Incentive Program

Alternative Housing and Incentive Program Manual - 03/2022
AHIP Request Form- 03/2022

Lyft Resources

Schedule a Lyft ride
Video tutorial to schedule a Lyft ride
General support articles for Lyft Concierge