Wisconsin Tuberculosis Program Forms
- Latent Tuberculosis Infection (LTBI) Confidential Case Report Form, F-02265
- Latent Tuberculosis Infection (LTBI) Follow-up Form, F-44125
- 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)
Forms for the Wisconsin Department of Public Instruction
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. Please use the following instructions when completing these forms.
- Record of School Employee Examination, F-02284 (PDF)
- Wisconsin Tuberculosis (TB) Risk Assessment Questionnaire Screen for Wisconsin Public School Employees, F-02314A (PDF)
Questions regarding the two DHS forms above may be directed to the Department of Public Instruction State School Nurse and Health Services Consultant:
Louise Wilson, MS, BSN, RN, NCSN
School Nursing and Health Services Consultant
Wisconsin Department of Public Instruction
PO Box 7841
125 S. Webster St.
Madison, WI 53707
608-266-8857
For more information or questions, contact the Respiratory Diseases and International Health Unit or your Wisconsin local health department.
