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.

Contact Investigation Forms

• TB Contact Investigation Form and instructions (pdf).

Treatment of LTBI Forms

• Treatment of LTBI Data Form (pdf)

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.

• 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)