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.

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 9-2019


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


Clip 1 – Registration and Consents

Clip 1 Isolation Instructions 03-2019AmharicKoreanSpanishTagalogVietnamese
Clip 1 DOT Agreement 03-2019 AmharicKoreanSpanishTagalogVietnamese
Clip 1 VET Agreement 03-2020AmharicKoreanSpanishTagalogVietnamese
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 Initial/Monthly Clinical Assessment 10-2019
Clip 3 Active TB Case Summary 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 Notification Form (CureTB) for cases
Interntional 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

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 – November, 2019
AHIP Request Form– March 2020


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

Tuberculosis Orientation Plan for Public Health Nurses – NEW, July 2020
Tuberculosis Treatment Summary Template – Fillable PDF (print on letterhead) – NEW, July 2020
Tuberculosis Treatment Summary Template – Editable Word Doc (print on letterhead) – NEW, July 2020
Adverse Reaction Report Form 03-2019
Emergency Evacuation Planning Form