Topics
A to Z
Data &
 Statistics
Forms &
Publications
News &
Advisories
Licensing &
Certification
Rules &
Regulations
Public Health
Directory
Print this Article   Bookmark and Share
TB Program Forms
On this page...
Additional resources...


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


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, 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 or check the international transfer resources on our TB Resources page.



Reimbursement Forms

 


Drug Order Form