Wisconsin Tuberculosis Program Forms
- Wisconsin Case Management for Active TB Disease Treatment, P-00647 (PDF)
- Tuberculosis (TB) Risk Assessment Questionnaire Screen, (F-02314)(PDF)
- Tuberculosis INFECTION Initial Request for Medication, (F-00905) (PDF)
- Tuberculosis DISEASE Initial Request for Medication, (F-44000) (PDF)
- Medication Refill Request, (F-44126 "pink sheet") (PDF)
- Follow up on Therapy, (F-44125 "green sheet") (PDF)
- TB Suspect Case Data Form, (F-42001) (PDF)
- Interjurisdictional Tuberculosis Notification (F-42010) (PDF)
- Interjurisdictional TB Notification Follow-up, (F-42011) (PDF)
- Dispensary Pre-authorization for Non-routine TB Services, (F-01459) (PDF)
Wisconsin Department of Public Instruction Forms
Per Wisconsin Statutes §118.25, school boards must require a physical examination as a condition of employment for all school employees. The physical examination must include a screening questionnaire for tuberculosis (TB), and if indicated, a test to determine the presence or absence of infectious TB disease. Please use the two forms below to fulfill these requirements and to document results for each employee.
- Record of School Employee Examination, (F-02284) (PDF)
- Wisconsin Tuberculosis (TB) Risk Assessment Questionnaire Screen for Wisconsin Public School Employees, (F-02314A) (PDF)
For more information, please contact the Department of Public Instruction:
Louise Wilson, MS, BSN, RN, NCSN
School Nursing and Health Services Consultant
WI Department of Public Instruction
PO Box 7841
125 S. Webster St.
Madison, WI 53707
608-266-8857
louise.wilson@dpi.wi.gov
For more information or questions, contact the Respiratory Diseases and International Health Unit or your Wisconsin local health department.
