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
Chart Organization
Active TB Chart Organization
TB Infection Chart Organization
Chart Review
Clips
Clip 1 - Registration and Consents
Clip 1 Isolation Instructions | Amharic | Korean | Spanish | Tagalog | Vietnamese
Clip 1 DOT Agreement | Amharic | Dari | Korean | Pashto | Spanish | Tagalog | Vietnamese
Clip 1 VET Agreement | Amharic | Dari | Korean | Pashto | 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
Clip 2 - Medications
VDH Summary of Providers of Care
Clip 2 Medication List
Clip 2 DOT Log
Clip 2 DOT Log for 12 Dose 3HP
Clip 3 - Assessment
Clip 3 Initial/Monthly Clinical Assessment
Clip 3 Active TB Case Summary
Clip 3 TB & Newcomer Health History
Clip 3 TB Risk Assessment-512 and Instructions
Clip 3 Contact Registration Form
Clip 4 - Notes
Clip 4 Progress Notes
Clip 4 Clinician Orders & Progress Notes
Clip 5 - Lab Specimens
Clip 5 Bacteriology Flow Sheet
Clip 5 Lab Flow Sheet
Clip 5 Vision Monitoring
Clip 5 Hearing Monitoring
Clip 6 - External
Interjurisdictional Notification (IJN) Forms:
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
- 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 Introduction to Tuberculosis slide set - can be adapted and used for education during contact investigations
Alternative Housing Incentive Program
Alternative Housing and Incentive Program Manual
AHIP Request Form
Lyft Resources
Schedule a Lyft ride
Video tutorial to schedule a Lyft ride
General support articles for Lyft Concierge
Second Line Drugs
In the event that a patient requires a second line TB medication, complete the following worksheet.
Second Line Drug Program Worksheet
Video Enhanced Therapy
Other
- TB Medication Ordering and Billing
- Local Health Department TB Program Correctional Facility Checklist
- When and Where to Send an Interjurisdictional Notification Form
- Tuberculosis Orientation Plan for Public Health Nurses
- Tuberculosis Treatment Summary Template - Fillable PDF (print on letterhead) | English & Spanish | Spanish
- Tuberculosis Treatment Summary Template - Editable Word Doc (print on letterhead) | English & Spanish | Spanish
- Adverse Reaction Report Form
- Emergency Evacuation Planning Form
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