Texas Department of Health



Texas Department of State Health Services

Tuberculosis Forms/Literature Checklist

NAME: __________________________________________________ D.O.B.: _____ /_____ /_____ SS#: _____ /____ /______

Directions: Enter the date of the visit at the top of the column. Place a checkmark (() in the appropriate column to indicate that the listed forms/literature were issued to the patient.

| | | |Date |Date |Date |Date |

|Stock # |Version |Form Title | | | | |

|L-36 |English |General Consent and Disclosure | | | | |

| |Spanish | | | | | |

|TB-410 |English |Order to Implement Measures for a Client with Tuberculosis | | | | |

|TB-410A |Spanish | | | | | |

|TB-410B |English |Order to Implement Control Measures for Children with Tuberculosis | | | | |

| |Spanish | | | | | |

|TB-409 |English |Acknowledgement of Understanding-Provision of Antituberculosis Drugs | | | | |

|TB-409A |Spanish |Limited to Clients with MTB | | | | |

|TB-411 |English |Disclosure and Consent-Drug Therapy for Treatment of Tuberculosis Disease| | | | |

|TB-411A |Spanish | | | | | |

|TB-415 |English |Disclosure and Consent-Drug Therapy for Treatment of Latent Tuberculosis | | | | |

|TB-415A |Spanish |Infection | | | | |

| |Eng. / Sp. |Privacy Statement | | | | |

|TB-622 |English |Treatment Record | | | | |

|TB-619 |Spanish | | | | | |

|TB-618 |Vietnamese | | | | | |

|TB-621 |English |Preventive Treatment Record | | | | |

|TB-620 |Spanish | | | | | |

|TB-617 |Vietnamese | | | | | |

|Stock # |Version |Literature Title | |

|CDC-00-6469 |English |Questions and Answers About TB-2005 | | | | |

|CDC-web |Spanish | | | | | |

|CDC-00-5743 |English |Tuberculosis-Get the Facts!-2005 Eng./2006 Sp. | | | | |

|CDC-00-5772 |Spanish | | | | | |

|CDC-00-5738 |English |Tuberculosis-The Connection Between TB and HIV-2005 Eng./ 2006 Sp. | | | | |

|CDC-00-5745 |Spanish | | | | | |

|CDC-99-8218 |English |Get the Facts About TB Disease | | | | |

|CDC-99-9369 |Spanish/Eng |2005 Eng. /2008 Spanish / 2008 Tagalog | | | | |

|CDC-99-9365 |Tagalog/Eng | | | | | |

|CDC-99-8219 |English |What You Need to Know About TB Infection | | | | |

|CDC-99-9373 |Spanish/Eng |2005 Eng. /2008 Spanish / 2008 Tagalog | | | | |

|CDC-99-9366 |Tagalog/Eng | | | | | |

|CDC-99-8220 |English |What You Need to Know About the TB Skin Test 2005 Eng. /2008 Spanish / | | | | |

|CDC-99-9368 |Spanish/Eng |2008 Tagalog | | | | |

|CDC-99-9367 |Tagalog/Eng | | | | | |

|CDC-99-8221 |English |Protect Your Family and Friends Against TB: The TB Contact Investigation | | | | |

|CDC-99-9370 |Spanish/Eng |2005 Eng. /2008 Spanish / 2008 Tagalog | | | | |

|CDC-99-9362 |Tagalog/Eng | | | | | |

|CDC-99-8222 |English |Take Steps to Control TB when You have HIV 2005 Eng. /2008 Spanish / 2008| | | | |

|CDC-99-9372 |Spanish/Eng |Tagalog | | | | |

|CDC-99-9360 |Tagalog/Eng | | | | | |

|CDC-99-8223 |English |Staying on Track with TB Medicine | | | | |

|CDC-99-9371 |Spanish/Eng |2005 Eng. /2008 Spanish / 2008 Tagalog | | | | |

|CDC-99-9363 |Tagalog/Eng | | | | | |

|DSHS-Bete |English |TB--What You Should Know | | | | |

| |Spanish | | | | | |

| |Vietnamese | | | | | |

|DSHS -Bete |English |TB And HIV—Know The Risks | | | | |

| |Spanish | | | | | |

|Nurse’s Initials | | | | |

TB-204 Forms/Literature Checklist – 10/08

Texas Department of State Health Services

Tuberculosis Forms/Literature Checklist (Continued)

| | | |Date |Date |Date |Date |

|Stock # |Version |CDC Fact Sheet Title | | | | |

|CDC-web |English |TB General Information (2008) | | | | |

|CDC-web |English |BCG Vaccine (2006) | | | | |

|CDC-web |English |The Difference Between Latent TB Infection and Active TB | | | | |

| | |Disease (2008) | | | | |

|CDC-web |English |TB Can Be Treated | | | | |

|CDC-web |English |Exposure to TB | | | | |

|CDC-web |English |TB and HIV/AIDS | | | | |

|CDC-web |English |You Can Prevent TB | | | | |

|CDC-web |English |Testing for TB | | | | |

|CDC-web |English |Multidrug-Resistant Tuberculosis (MDR TB) (2008) | | | | |

| |Spanish | | | | | |

|CDC-web |English |Extensively Drug-Resistant Tuberculosis (XDR TB) (2007) | | | | |

| |Spanish | | | | | |

|CDC-web |English |CDC’s Role in Preventing Extensively Drug-Resistant | | | | |

| |Spanish |Tuberculosis (XDR TB) (2007) | | | | |

|CDC-web |English |Recommendations for Human Immunodeficiency Virus (HIV) | | | | |

| | |Screening in Tuberculosis (TB) Clinics (2008) | | | | |

|CDC-web |English |QuantiFERON-TB Gold Test (2007) | | | | |

|CDC-web |English |Tuberculin Skin Testing (2006) | | | | |

|CDC-web |English |Diagnosis of Tuberculosis Disease (2008) | | | | |

|CDC-web |English |Targeted Tuberculin Testing and Interpreting Tuberculin Skin | | | | |

| | |Test Results (2005) | | | | |

|CDC-web |English |Treatment of Latent TB Infection (2007) | | | | |

|CDC-web |English |Treatment of Latent Tuberculosis Infection: Maximizing | | | | |

| | |Adherence (2005) | | | | |

|CDC-web |English |Treatment Options for Latent Tuberculosis Infection (2005) | | | | |

|CDC-web |English |Tuberculosis in Blacks (2008) | | | | |

|CDC-web |English |Tuberculosis Information for Employers in Non-Healthcare| | | | |

| | |Settings (2007) | | | | |

|CDC-web |English |Tuberculosis in Minorities (2008) | | | | |

|CDC-web |English |Tuberculosis Information for International Travelers (2008) | | | | |

| |Spanish | | | | | |

|CDC-web |English |Tuberculosis and Pregnancy (2008) | | | | |

| | | | | | | |

|Nurse’s Initials | | | | |

TB-204 Forms/Literature Checklist – 10/08

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