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.
Stock # / Version / Form Title / Date / Date / Date / DateL-36 / English
Spanish / General Consent and Disclosure
TB-410
TB-410A / English
Spanish / Order to Implement Measures for a Client with Tuberculosis
TB-410B / English
Spanish / Order to Implement Control Measures for Children with Tuberculosis
TB-409
TB-409A / English
Spanish / Acknowledgement of Understanding-Provision of Antituberculosis Drugs Limited to Clients with MTB
TB-411
TB-411A / English
Spanish / Disclosure and Consent-Drug Therapy for Treatment of Tuberculosis Disease
TB-415
TB-415A / English
Spanish / Disclosure and Consent-Drug Therapy for Treatment of Latent Tuberculosis Infection
Eng. / Sp. / Privacy Statement
TB-622
TB-619
TB-618 / English
Spanish
Vietnamese / Treatment Record
TB-621
TB-620
TB-617 / English
Spanish
Vietnamese / Preventive Treatment Record
Stock # / Version / Literature Title
CDC-00-6469
CDC-web / English
Spanish / Questions and Answers About TB-2005
CDC-00-5743
CDC-00-5772 / English
Spanish / Tuberculosis-Get the Facts!-2005 Eng./2006 Sp.
CDC-00-5738
CDC-00-5745 / English
Spanish / Tuberculosis-The Connection Between TB and HIV-2005 Eng./2006 Sp.
CDC-99-8218
CDC-99-9369
CDC-99-9365 / English
Spanish/Eng
Tagalog/Eng / Get the Facts About TB Disease
2005 Eng. /2008 Spanish / 2008 Tagalog
CDC-99-8219
CDC-99-9373
CDC-99-9366 / English
Spanish/Eng
Tagalog/Eng / What You Need to Know About TB Infection
2005 Eng. /2008 Spanish / 2008 Tagalog
CDC-99-8220
CDC-99-9368
CDC-99-9367 / English Spanish/Eng
Tagalog/Eng / What You Need to Know About the TB Skin Test 2005 Eng. /2008 Spanish / 2008 Tagalog
CDC-99-8221
CDC-99-9370
CDC-99-9362 / English
Spanish/Eng
Tagalog/Eng / Protect Your Family and Friends Against TB: The TB Contact Investigation
2005 Eng. /2008 Spanish / 2008 Tagalog
CDC-99-8222
CDC-99-9372
CDC-99-9360 / English
Spanish/Eng
Tagalog/Eng / Take Steps to Control TB when You have HIV 2005 Eng. /2008 Spanish / 2008 Tagalog
CDC-99-8223
CDC-99-9371
CDC-99-9363 / English
Spanish/Eng
Tagalog/Eng / Staying on Track with TB Medicine
2005 Eng. /2008 Spanish / 2008 Tagalog
DSHS-Bete / English
Spanish
Vietnamese / TB--What You Should Know
DSHS -Bete / English
Spanish / TB And HIV—Know The Risks
Nurse’s Initials
TB-204 Forms/Literature Checklist – 10/08
Texas Department of State Health Services
Tuberculosis Forms/Literature Checklist (Continued)
Stock # / Version / CDC Fact Sheet Title / Date / Date / Date / DateCDC-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
Spanish / Multidrug-Resistant Tuberculosis (MDR TB) (2008)
CDC-web / English
Spanish / Extensively Drug-Resistant Tuberculosis (XDR TB) (2007)
CDC-web / English
Spanish / CDC’s Role in Preventing Extensively Drug-Resistant 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
Spanish / Tuberculosis Information for International Travelers (2008)
CDC-web / English / Tuberculosis and Pregnancy (2008)
Nurse’s Initials
TB-204 Forms/Literature Checklist – 10/08