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Tuberculosis (TB) Forms

• Anti-tuberculosis Therapy Program, Initial Request for Medication (DPH 4000)  
  (PDF, 37 KB)
• Medication Refill Request (DPH 4126--"pink sheet") (PDF, 8 KB)
• Follow Up on Therapy (DPH 4125--"green sheet") (PDF, 8 KB)
• TB Suspect Case Data Form (DPH 42001)
  (PDF, 25 KB)  
• Interjurisdictional Tuberculosis Notification Form (DPH 42010)  
  (PDF, 21 KB)
  • locate information about receiving jurisdiction (NTCA) (Exit DHFS)
• Interjurisdictional TB Notification - Follow-up (DPH 42011)  
  (PDF, 19 KB)

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Last Revised: March 21, 2008