{"id":20,"date":"2019-10-03T14:00:32","date_gmt":"2019-10-03T18:00:32","guid":{"rendered":"https:\/\/www.vdh.virginia.gov\/tuberculosis\/?page_id=20"},"modified":"2026-03-10T15:50:15","modified_gmt":"2026-03-10T19:50:15","slug":"forms-for-local-health-departments","status":"publish","type":"page","link":"https:\/\/www.vdh.virginia.gov\/tuberculosis\/forms-for-local-health-departments\/","title":{"rendered":"Forms for Local Health Departments"},"content":{"rendered":"
\n\t\t\t\n\t\t\n\t\t\t\n\t\t\tVDH TB Central Resource Hub\t\t<\/span>\n\t\t\t<\/a>\n\t<\/div>\n<\/div><\/div><\/div>
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Chart (New)<\/h2>\n

All individuals who are reported to the health department as a presumed or confirmed case of active TB disease, regardless of the source of care, should have a permanent VDH medical record.\u00a0 The Recommendations for TB Record and Form Use<\/a> Recommendations for TB Record and Form Use\u00a0<\/span>should be referenced when using the documents found on this page.<\/p>\n

The TB Nurse Case Management Clinical Pathway<\/a> provides a sequential list of tasks, decisions, and interventions performed during the care of a presumptive or confirmed TB case.\u00a0 This tool has been developed for TB nurse case managers to use during the management of their patients.\u00a0 The clinical pathway was updated in August 2021.<\/p>\n

Please review VDH TB Program Reporting Guidance<\/a> for information on how to report new confirmed\/presumptive active TB cases, LTBI cases, and information on contact investigations. An infographic illustrating the reporting flow is also available here: VDH TB Reporting Guidance Visual<\/a>.<\/p>\n

Please use this form<\/a> and email\/fax cover letter<\/a>\u00a0to conduct initial or follow-up outreach to community providers regarding cases of LTBI. Once completed, you may create or update the investigation in VEDSS directly, or you may send it to Central Office for VEDSS entry.<\/p>\n

Slides from the April 3rd, 2019 TB Materials release session: TB Materials Training<\/a><\/p>\n

A summary of changes to the Monthly TB Clinical Assessment Form, now titled Initial\/Monthly Clinical Assessment Form: Changes to the Monthly TB Clinical Assessment Form<\/a><\/p>\n

Chart Organization<\/h3>\n

Active TB Chart Organization<\/a>
\nTB Infection Chart Organization<\/a><\/p>\n

Chart Review<\/h3>\n

VDH Nursing Peer Chart Review Toolkit Forms and Instructions<\/a>
\nTuberculosis Chart Review Tool<\/a><\/p>\n<\/div>\n<\/div><\/div>

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Clips<\/h2>\n

Clip 1 - Registration and Consents<\/h3>\n

Clip 1 Isolation Instructions<\/a> |\u00a0Amharic<\/a> |\u00a0Korean<\/a> |\u00a0Spanish<\/a> |\u00a0Tagalog<\/a> |\u00a0Vietnamese<\/a>
\nClip 1 DOT Agreement<\/a> | Amharic<\/a> | Dari<\/a> | Korean<\/a> | Pashto<\/a> | Spanish<\/a> |\u00a0Tagalog<\/a> |\u00a0Vietnamese<\/a>
\nClip 1 VET Agreement<\/a>\u00a0| Amharic<\/a> | Dari<\/a> | Korean<\/a> | Pashto<\/a> | Spanish<\/a> | Tagalog<\/a> |\u00a0Vietnamese<\/a>
\nClip 1 TB Case Completion\/Discontinue Report & Worksheet (Case Closure Form)<\/a>
\nClip 1 RVCT (Report of Verified Case of Tuberculosis)<\/a>
\nCompleting the Report of Verified Case of Tuberculosis using TB Chart Forms<\/a><\/p>\n

Clip 2 - Medications<\/h3>\n

Clip 2 VDH Summary of Providers of Care<\/a>
\nClip 2 Medication List<\/a>
\nClip 2 DOT Log<\/a>
\nClip 2 DOT Log for 12 Dose 3HP<\/a><\/p>\n

Clip 3 - Assessment<\/h3>\n

Clip 3 Initial\/Monthly Clinical Assessment<\/a>
\nClip 3 Active TB Case Summary<\/a>
\nClip 3 TB & Newcomer Health History<\/a>
\nClip 3 TB Risk Assessment-512 and Instructions<\/a>
\nClip 3 Contact Registration Form<\/a> | Arabic<\/a> | Dari<\/a> | Hindi<\/a> |\u00a0Pashto<\/a> | Russian<\/a> | Spanish<\/a> |\u00a0Ukrainian<\/a> | Vietnamese<\/a><\/p>\n

Clip 4 - Notes<\/h3>\n

Clip 4 Progress Notes<\/a>
\nClip 4 Clinician Orders & Progress Notes<\/a><\/p>\n

Clip 5 - Lab Specimens<\/h3>\n

Clip 5 Bacteriology Flow Sheet<\/a>
\nClip 5 Lab Flow Sheet<\/a>
\nClip 5 Vision Monitoring<\/a>
\nClip 5 Hearing Monitoring<\/a><\/p>\n

Clip 6 - External<\/h3>\n

Interjurisdictional Notification (IJN) Forms:<\/p>\n