Name (last, first, MI)
Street address
City, State, Zip
County Phone / 2. Birth date://
3. Sex: male female
4. Country of origin:
United States
other:
5. Health care provider:
Name (first, last, degree, i.e. MD, DO, NP, PA)
Phone
Fax
Clinic
Street address
City, State, Zip
6. Indication for TB screening:
foreign-born from high-prevalence area
CXR indicating stable, inactive TB
recent contact to known infectiousactive TB
medical condition (e.g., HIV-infected, organ transplant, diabetes substance abuse, immunosuppression)
correctional facility inmate
nursing home resident
drug treatment facility resident
homeless
migrant worker
employee screening
other:
7. Tuberculin skin test date://
Result:positive* (mm#)
negative
and/or
IGRA (TB blood) test date://
Result:positivenegative
indeterminate
* Interpretation depends on the person’s risk factors for TB
# Measure crosswise axis of forearm, record mm induration / 8. Chest X-ray date: //
CXR should be done ≤ 6 months before treatment is started (≤ 3 months for high risk [i.e., young child, new converter, immunocompromised, prior abnormal CXR, or other risk factors]).
Result:
normal (negative for active TB)
abnormal but not consistent with active TB
other (please include copy of report)
9. Has clinician ruled out active TB disease?
Yes(i.e., CXR negative for active TB and no TB-
related symptoms or physical findings. To prevent
the development of drug-resistant TB, LTBI
treatment should not be started until active TB
disease has been ruled out. Report suspected
active TB disease to MDH at 651-201-5414 or
1-877-676-5414).
10. Additional questions:
a. Does the patient have any drug allergies?
No Yes - please specify:
b. Does the patient have a chronic medical condition?
No Yes - please specify:
c. Is the patient currently taking any prescription or
non-prescription drugs? (or attach sheet)
No Yes - please specify or attach sheet:
11. Medication(s) requested:
Patient’s weight:lbs/kg (required for children & adultsdosed < maximum per CDC guidelines)
Drug / Dosage / Frequency / Length of Regimen (mos.) / Start Date:(needed if patient has already started treatment)
Isoniazid (INH)
Other: / Rationale for alternative regimen:
For INH requests only: Vitamin B6:
Vitamin B6supplementation to prevent neuropathy is not routinely recommended. MDH will supply Vitamin B6 if clinically indicated.Check box(es) at right.
25 mg. daily 50 mg. daily / Indication for Vitamin B6(pyridoxine):
diabetes malnutrition breastfeeding
renal failure HIV infection pregnancy
alcoholism seizure disorder
infant who is >50% breastfed and taking INH;
recommended Vitamin B6 dose: 6.25 mg daily
I have attached the signed prescription(s) (REQUIRED).
Please label themedication bottle in Spanish.
12. Send medications to: (must be a health care provider licensed to administer medications):
Name:
Same as provider (#6) Clinic/Agency:
Address:
Phone:
You will receive the first month’s supply of medication within 5 working days of request.
After treatment starts, complete & return the start date verification formincluded in the initial shipment.Upon receiving this verification, MDH will ship refills monthly until treatment is complete.
Unused medication cannot be returned to MDH or the pharmacy. If treatment is discontinued for any reason or patient is lost to follow-up, please contact MDH ASAPto stop shipments.
LTBI treatment guidelines ( monthly monitoring by a health care provider throughout treatment to evaluate for adverse drug effects, signs/symptoms of active TB and patient adherence. A suggested LTBI monitoring flow sheet is available at
13. Form completed by:Name:
Same as provider (#6)Agency:
Same as “send to” (#12) Phone: (please provide direct line if possible)
Form has been reviewed for completeness (Note: forms will be returned to the requestor if
incomplete or if signed prescription is missing. This will delay processing your request.)
Notes:
Page 2 Revised, May 2012