Get Interjurisdictional Tuberculosis Notification Form

Completing the Interjurisdictional Tuberculosis Notification Form online is an essential step in reporting tuberculosis cases and ensuring effective public health responses. This guide will walk you through each section of the form to help you provide accurate and timely information.

Follow the steps to complete the form correctly.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Enter the referring jurisdiction by specifying the city and county where the case is reported. Provide the contact person's phone number and fax number if applicable.
3. Indicate whether the case is a verified case, a suspect case, or if it is not reported. Fill in the state where the case is reported, along with the date the form is being sent.
4. Input the patient's demographics: first name, last name, date of birth, and sex (male or female). Determine if an interpreter is needed and note the patient's race and ethnicity.
5. Provide details regarding the patient's expected arrival, including city, state, and zip code.
6. Indicate the health provider information, whether it is unknown or known (include the name, address, and phone number if available).
7. Specify the insurance source, such as none, Medicaid, private insurance, or Medicare.
8. Fill in the laboratory information relevant to the referred case or suspect, including specimen type, results from TB skin tests, chest x-rays, and any other pertinent labs.
9. Document contact or LTBI information for the patient, including last known exposure to the index case, and any relevant medication details.
10. Provide comments on adherence problems or significant drug side effects, if applicable.
11. Fill out case follow-up details, indicating whether follow-up is requested and any relevant time frames for reporting outcomes.
12. Once all sections are complete, save your changes. You may also download, print, or share the form as needed.

Take the first step in public health and complete your documents online today.