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TB Forms

Form Number Form Name
COT Letter Completion of TB Treatment Letter
DOT Invoice DOT Invoice Template
Send Out Letter Send Out Letter for Billing
TB-9 X-Ray Record Card
TB-15-P Monthly Tuberculin Testing Report - PRIVATE PAY (rev. 8/2015)
TB-15-S Monthly Tuberculin Testing Report - STATE SUPPORTED (rev. 8/2015)
TB-18 Supply Order and Inventory FormĀ (rev. 9/2018)
TB-20 Attendance Sheet - Chest Clinic (rev. 2/2013)
TB-21 Summary Clinic Activity Sheet (Individual - Optional)
TB-34 Individual Tuberculosis Report
TB-34 Individual Tuberculosis Report (MS Excel)
TB-40 Appointment Card
TB-60 Individual Record of Tuberculin Skin Test (rev. 10/2012)
TB-61 Return for Skin Test Reading Card
TB-70S School Nurse Referral to LHD (7/2016)
TB-80 Diagnostic Clinic Form (9/2016)
TB-101 Tuberculosis Record (LTBI-Reporting Form, rev. 10/2018)
TB-102 Refusal of Treatment Form, Adult (rev. 1/2018)
TB-103 Parental Refusal (rev. 1/2018)
TB-104 TB Risk Assessment (rev. 1/2018)
TB-105 Nursing History (rev. 2/2013)
TB-106 Consent for Treatment, Common meds (rev. 1/2017)
TB-106 Consent for Treatment, Uncommon meds (rev. 1/2017)
TB-107 DOT Treatment Record (rev. 2/2013)
TB-109 Active or Suspect Pathway (rev. 3/2013)
TB-110 LTBI Pathway (rev. 3/2013)
TB-111 Tuberculosis Clinic Notes (Optional)
TB-112 Report of Tuberculosis Screening
TB-113 Free of TB Letter (rev. 3/2013)
TB-115 Smear Culture Log (rev. 7/2013)
TB-1001 Contact Sheet (rev. 9/2014)
TB-1006 Diagnostic Clinic Sheet (rev. 2/2013)
TB-1007 X-Ray Clinic Record (rev. 2/2013)
TB-150 Workers Log (rev. 2/2013)