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TB Form Deadline Summary Charts


Case Forms

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

  • TB is one of the primary differential diagnoses.  This often occurs when:
    • Signs and symptoms of TB are present and/or
    • The patient has an abnormal chest x-ray consistent with TB or
    • The patient is started on multi-drug therapy for TB
  • When specimen smears are positive for acid fast bacilli (AFB)
  • When the patient has a positive culture for M. tuberculosis complex (e.g. M. tuberculosis, M. bovis, M. canetti, M. africanum)
  • 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 (Revised 8/4/2011) and Instructions (pdf) (Revised 4/16/2012)
    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.


LTBI Screening and Treatment Forms
  • TB Screening Questionnaire (pdf), in English and Spanish
  • LTBI Test and Treatment Cards for Patients, in English and Spanish
  • Treatment of LTBI Data Form (pdf) (Revised 03/2012)
    Please submit the Treatment of LTBI Data Form for clients treated for LTBI, excluding TB contacts that have been submitted via the contact investigation form above.


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

In State Transfers

For transferring cases, contacts, LTBI and B-waivers within the state of Oregon, please see the instructions for Transfers Within Oregon (pdf).

For transferring contacts within the state of Oregon, complete the Contact Transfer Form (pdf) and send to the appropriate local health department. If receiving this contact transfer form, please record all evaluation and treatment information on the form and send back to the referring local health department at end of follow-up (please send a copy to the State as well).

Out of State Transfers

For transfers out of Oregon but within the U.S., complete the Interjurisdictional TB Notification From (IJN) and fax to the receiving jurisdiction.  Directions on completing the form are on the NTCA website.  Contact information for each state can be found here: State TB Control Programs. If the patient is a case or contact, fax us a copy of the referral at 971-673-0178.
 
If you receive a transfer to your jurisdiction, you must inform the referring jurisdiction whether or not you have located the patient and the final outcome.  Complete and forward the Interjurisdictional TB Notification Follow-Up Form to the referring jurisdiction and send a copy to the State.   If you are following up on a patient with TB disease, please fill out the CDC Completion Form (Follow-up 2)(pdf) once treatment is completed and submit to the referring jurisdiction for their records (copy the OR State TB Program).
 

For international transfers or other transfer assistance, please contact the State TB Program or check the international transfer resources on our TB Resources page.



Reimbursement Forms

 


Drug Order Form

 


Special Needs Fund Request