TB Control Programs's Record System

To provide an organizational framework that enables records to become goal oriented, communicative, and relevant.
To provide health professionals with immediate information and progress in management of a problem.
To document the medical process and the medical services provided.

Forms are listed according to use. Forms listed in Bold are also to be sent to WV TB Control Program.

Form Number	Form Name
TB-M-108	Retention and Disposal of Tuberculosis Records
TB-104	TB Risk Assessment
TB-60	Individual Record of Tuberculin Skin Test
TB-61	Return for Skin Test Reading Card
TB-M-136	Classification of TB Skin Test Reactors
TB-101	Tuberculosis Record (LTBI-Reporting Form)
TB-112	Report of Turberculosis Screening
TB-40	Appointment Card
TB-15	Monthly Tuberculin Testing Report
TB-9	X-Ray Record Card
TB-1007	X-Ray Clinic Sheet
TB-105-R	Nursing History
TB-20	Attendance Sheet (Chest Clinic)
TB-21-R	Summary Clinic Activity Sheet (Individual) (Optional)
TB-111	Tuberculosis Clinic Notes (Optional)
TB-1006-R	Diagnostic Clinic Sheet
TB-106	Consent for Treatment
TB-102	INH Refusal
TB-107	Treatment Record
TB-50	Drug Record
TB-34	Individual Tuberculosis Report
TB-70	"Dear Doctor" Form Letter
TB-1001	Contact Sheet
TB-109	Clinical Pathway - Active Cases
TB-110	Clinical Pathway - LTBI
TB-LTBI	Cards for COT [English, Spanish, Creole]
TB-18-A	Drug Order Form
TB-18-B	Drug Inventory Form
ARPE	Follow-Up and Treatment for Contacts to Tuberculosis Cases
ARPE	Target Testing and Treatment for Latent Tuberculosis Infection

Division of Surveillance & Disease Control