Tuberculosis Forms

Case Forms

• TB Disease Case Report Form (pdf) and instructions (pdf)
• DOT Agreement Form (pdf) also available in Spanish (pdf)
• Isolation Agreement Form (pdf) also available in Spanish (pdf)

Reports should be made when any of the following is true:

1. TB is one of the primary differential diagnoses.  This often occurs when:
   1. Signs and symptoms of TB are present and/or
   2. The patient has an abnormal chest x-ray consistent with TB or
   3. The patient is started on multi-drug therapy for TB
2. When specimen smears are positive for acid fast bacilli (AFB)
3. When the patient has a positive culture for M. tuberculosis complex (e.g. M. tuberculosis, M. bovis, M. canetti, M. africanum)
4. When a pathology report is consistent with tuberculosis.

When a TB case is first reported, please submit the case report form, as well as Chest X-ray/CT readings.  Update the case report upon TB verification and case closure.

Contact Investigation Forms

• TB Contact Investigation Form and instructions (pdf).

Please submit the contact investigation form 1) after first round screening 2) after second round screening and 3) after any contacts diagnosed with LTBI have completed their treatment course.

Treatment of LTBI Forms

• Treatment of LTBI Data Form (pdf)

Submit the LTBI Data Form for clients treated for LTBI, excluding clients that have been submitted via the contact investigation form above.

Transfer Forms (Case, Contact, LTBI, B-waiver)

• For transfers out of Oregon or to another jurisdiction within Oregon, complete the Transfer Notification Form (pdf) and send to the receiving jurisdiction. Send a copy to the State. Contact information for the different State TB Control Programs can be found here.

   

• If you receive a transfer to your jurisdiction, you must inform the referring jurisdiction whether or not you have located the individual and will be continuing treatment. Complete and forward the Transfer Follow-up Form (pdf) to the referring jurisdiction and send a copy to the State.  If treatment of the transfer case will be continued in your jurisdiction, please fill out the CDC Completion Form (Follow-up 2)(pdf) once treatment has been completed and submit to the referring jurisdiction for their records (again, please cc the OR State TB Program).

   

• For more details, refer to Interjurisdictional Transfer Instructions (pdf).  For international transfers or other transfer assistance, please contact the State TB Program.

Reimbursement forms

• Chest X-ray Authorization/Reimbursement Form (pdf)
• DOT Incentive/Enabler Protocol and Request Form (pdf)
• Drug Order Form (pdf)