TB: Forms and Publications

• Financial Assistance for TB or LTBI - Fact Sheet, P-03549 (PDF): A fact sheet to spread awareness of financial resources available to TB / LTBI clients, with a spot for LTHD contact information.
• TB Disease Initial Request for Medication, F-44000 (PDF): Fill out this form to request medication for active TB disease from the WTBP.
• TB Infection Initial Request for Medication, F-00905 (Word): Fill out this form to request medication for LTBI from the WTBP.
• Medication Refill Request, F-44126: (PDF) Fill out this form to request a refill on medication for active TB disease from the Wisconsin TB Program Dispensary.
• Ordering Latent Tuberculosis Infection (LTBI) Medications though the Wisconsin Tuberculosis Dispensary Program, P-02404 (PDF): Instructions for ordering LTBI medications through the Wisconsin TB Dispensary Program
• Ordering Active Tuberculosis Medications through the Wisconsin TB Dispensary Program, P-02404A (PDF): Instructions for order medications for active TB disease through the Wisconsin Dispensary Program
• TB Ordering and Billing Interface (TOBI) User Security and Confidentiality Agreement, F-02163 (PDF): Fill out this form and return to the WTBP for access to TOBI.
• Wisconsin Medicaid and BadgerCare Plus TB-Related Services Only, P-10022: See this fact sheet for information on the TB-services only Wisconsin Medicaid plan (available in Dari, Hmong, Burmese, Kirundi, Russian, Spanish, and Ukrainian)

• Tuberculosis (TB) Treatment Assistance Program- Request for Reimbursement, F-02463 (PDF): Use this form to request reimbursement from the Wisconsin TB Treatment Assistance Program.
• Tuberculosis (TB) Treatment Assistance Enrollment and Agreement, F-02462 (PDF): Fill out this form to enroll your health department in the Wisconsin TB Treatment Assistance Program.
• Tuberculosis (TB) Treatment Assistance Special Request, F-02461 (PDF): Use this form to request assistance above capped rates for the Wisconsin TB Treatment Assistance Program.
• Wisconsin Tuberculosis (TB) Treatment Assistance Program Policies and Procedures, P-02365: (PDF) Use this manual for accessing the Wisconsin TB Treatment Assistance Program.

• TB Risk Assessment Questionnaire, F-02314 (also in Spanish): A worksheet to determine a person's risk for TB infection and disease.
• TB Risk Assessment Questionnaire Screen for Wisconsin Public School Employees, F-02134A: (PDF) A worksheet to determine a person's risk for TB infection and disease, for use to screen Wisconsin public school staff.
• TB Risk Assessment and Symptom Evaluation for Annual Employment Screening, F-02314E. (PDF) A worksheet to determine need for repeat TB testing after baseline for health care personnel.
• Tuberculosis Screening and Testing: Health Care Personnel and Caregivers, P-02382 (PDF): A fact sheet outlining recommendations for screening health care workers in Wisconsin.
• Decision Tree: Tuberculosis Screening of Health Care Personnel (HCP) and Caregivers upon Hire, P-02530: (PDF) An algorithm outlining TB screening for HCP and caregivers in Wisconsin.
• Tuberculosis Screening and Testing: Residents of Care Facilities, P-02382A: (PDF) A fact sheet outlining recommendations for screening residents of nursing homes, assisted living, and other care facilities.
• Decision Tree: Tuberculosis Screening of Patients/Residents upon Admission to Care Facilities, P-02529: (PDF) An algorithm outlining TB screening for admission of patients/residents to Wisconsin Facilities.
• Positive TST-What's next? P-02288: (PDF) A fact sheet outlining steps to take after a positive skin test result.
• Positive IGRA-What's next? P-01182: (PDF) A fact sheet outlining steps to take after a positive Interferon Gamma Release Assay (IGRA) result.
• Tuberculosis (TB) Screening for People Arriving from Ukraine to Wisconsin, P-03293: (PDF) Recommended components of tuberculosis (TB) screening for Ukrainians participating in the Uniting for Ukraine (U4U) program.
• Wisconsin Tuberculosis Record Card, P-03429: A record card for documenting client TB and LTBI screening and treatment. The card is available in to order English. (PDF) Reference versions are available in Dari, Hmong, Kirundi, Russian, Burmese, Ukrainian, and Spanish
• Wisconsin Tuberculosis (TB) Screening Tool for Ukrainian Humanitarian Parolees (UHP) Participating in the Uniting for Ukraine Program (U4U), P-03293a (PDF): Tool for completing recommended components of tuberculosis (TB) screening for Ukrainians participating in the Uniting for Ukraine (U4U) program.
• Follow-Up for IGRA Reports, P-02540 (PDF): A checklist for public health staff on what's next after an IGRA

• TB Suspect Case Data Form, F-42001 (PDF): Use this form to report suspected active cases of TB.
• Active TB Disease Follow-up Form, F-02474 (PDF): Use this form to communicate and document follow-up at the end of active TB treatment.
• Latent Tuberculosis Infection (LTBI) Confidential Case Report Form, F-02265 (PDF): Use this form to report cases of LTBI to your local health department.
• Latent Tuberculosis Infection (LTBI) Follow-up Form, F-44125: (PDF) Use this form to communicate and document follow-up at the end of LTBI treatment.
• Interjurisdictional Tuberculosis Notification, F-42010 (PDF): Use this form to transfer cases to another jurisdiction in Wisconsin.
• Interjurisdictional TB Notification Follow-up, F-42011 (PDF): Use this form to follow up with cases who transferred to another jurisdiction in Wisconsin during treatment.
• Communicable Disease Case Reporting and Investigation Protocol: Latent Tuberculosis Infection (LTBI), P-02303 (PDF): A protocol on reporting latent TB infection (LTBI).
• Documenting Latent Tuberculosis Infection (LTBI) in the Wisconsin Electronic Disease Surveillance System (WEDSS), P-02426 (PDF): Instructions for how to document LTBI cases reported to your local health department.
• Communicable Disease Case Reporting and Investigation Protocol: Tuberculosis (TB), P-01928: (PDF) A protocol on reporting active TB disease.

• Active Tuberculosis Disease Fact Sheet, P-42099 – A fact sheet with information on TB infection and TB disease, how TB spreads, signs and symptoms, prevention, and treatment, available in English, Hmong, Spanish, Russian, Burmese, Dari, Kirundi, and Ukrainian.
• Latent Tuberculosis Infection Fact Sheet, P-42099b – A fact sheet with information on TB infection, medicine, testing, prevention, and treatment, available in English, Hmong, Spanish, Russian, Dari, Kirundi, and Ukrainian.
• How can I prevent tuberculosis (TB)? P-02504: An infographic outlining steps people can take to prevent TB (also available in Dari, Hmong, Burmese, Kirundi, Russian, Ukrainian, and Spanish).
• LTBI FAQ Sheet, P-02429: (PDF) Frequently asked questions about LTBI.
• Wisconsin TB cases by local public health regions and county, P-00438: (PDF) A fact sheet with number of active TB disease cases by region and county
• Latent Tuberculosis Infection (LTBI) Treatments, P-01181: (PDF) See this fact sheet for information on recommended treatment for LTBI.

• Statement on four-month HPMZ Regimen for TB Disease, P-03422: (PDF) Wisconsin TB Program Statement on the four-month HPMZ Regimen for TB Disease.
• Nurse Case Management Checklist and Timeline, P-00647: (PDF) A guide for case management activities to be completed by nurses at local health departments.
• LTBI FAQ Sheet, P-02429: (PDF) Frequently asked questions about LTBI.
• Latent Tuberculosis Infection (LTBI) Treatments, P-01181: (PDF) See this fact sheet for information on recommended treatment for LTBI.
• Sputum Collection: Spontaneously Produced, P-02380: (PDF) A fact sheet for nursing staff on how to collect sputum specimens.
• Sputum Collection: Nebulized Induction, P-02381: (PDF) A fact sheet for nursing staff on how to collect sputum specimens.
• Hospital Discharge Checklist for Active/Suspect Tuberculosis (TB) Disease, P-02849 (PDF) A checklist for local health departments to coordinate safe discharge from the hospital for patients with confirmed and suspected active TB.
• Home Isolation Agreement, P-02969 (PDF) – An agreement form for local health departments to educate clients with active infectious TB disease on home isolation.
• Wisconsin Electronic Video Directly Observed Therapy (eDOT), P-03325 (PDF) Recommendations for local and Tribal health departments considering implementing video eDOT in their tuberculosis programs.
• CDC Medication Trackers and Translations by SNTC
• Do You Know Your HIV Status?, P-03576 (PDF) – A fact sheet for clients diagnosed or suspected with active TB disease to provide education on why HIV screening is recommended.
• Do You Know Your Patient's HIV Status?, P-03576A (PDF) – A fact sheet for providers and other clinicians on why HIV screening is recommended for patients diagnosed or suspected with active TB disease.

• Wisconsin TB cases by local public health regions and county, P-00438: (PDF) A fact sheet with number of active TB disease cases by region and county.
• Tuberculosis in Wisconsin one-page fact sheet, P-02194A (also available in Dari, Hmong, Kirundi, Russian, Ukrainian, and Spanish) gives an overview of TB statistics.

Biosafety Recommendations for Individuals Handling Carcasses from Animals Known or Suspected to Have Tuberculosis, P-00295: (PDF) A fact sheet with information for safe management of animal carcasses.

• Class B1/B2 Tuberculosis Notification, P-01709 (multiple languages): Information about class B notifications and follow-up recommendations.
• Recommendations for Local Health Departments Class B TB Follow-up, P-00619 (PDF): Follow-up recommendations for arrivals with a TB class condition.
• Refugee Medical Screen Guidance for Wisconsin Providers, P-02820 (PDF): Recommended components of the Refugee Medical Screening (RMS) for clinicians providing screening for recent refugee arrivals to Wisconsin.
• Tuberculosis (TB) Screening for People Arriving from Ukraine to Wisconsin, P-03293: (PDF) Recommended components of tuberculosis (TB) screening for Ukrainians participating in the Uniting for Ukraine (U4U) program.
• Wisconsin Tuberculosis (TB) Screening Tool for Ukrainian Humanitarian Parolees (UHP) Participating in the Uniting for Ukraine Program (U4U), P-03293a: (PDF) Tool for completing recommended components of tuberculosis (TB) screening for Ukrainians participating in the Uniting for Ukraine (U4U) program.

If you have questions about Refugee Health, please contact the State Refugee Health Coordinator at savitri.tsering1@wisconsin.gov or 608-422-6269.