Form 603.ltbi - Consent And Treatment Plan For Latent Tuberculosis Infection (Ltbi) With Directly Observed Therapy
ADVERTISEMENT
1Consent and Treatment Plan for
Latent Tuberculosis Infection (LTBI)
With Directly Observed Therapy
I, _______________________________, have been advised and counseled by _____________________________.
(Client’s Name)
(Public Health Representative/Title)
Based on available information, I (may) have latent tuberculosis infection (LTBI). The following has been explained to
me:
1. LTBI means I have been infected by the TB germ M. tuberculosis. My immune system has walled off the
germs to keep them dormant (sleeping). I have no symptoms and cannot spread the germ to others.
2. Without treatment, I can get sick with active TB disease and have symptoms such as cough, fever, night
sweats, weight loss or extreme tiredness. If any of these symptoms appear, I agree to call the health
department at ___________________ immediately.
3. I understand the link between TB and HIV and therefore I agree to be tested for HIV.
4. I agree to take my TB medication, as ordered via DOT for the entire length of treatment. I agree to
cooperate with the supervised DOT program to help remind me to take my medicine and to make sure I
complete my treatment. In this program, a designated public health employee or a trained DOT worker is
authorized as my agent to maintain possession of my medication and to be present when I take my TB
medicine.
5. I will be at: ___ home ___ work ___ clinic/lhd ___ other (specify) ________________________ between the
hours of ______ and ______ for my DOT visit. If I cannot meet at the agreed place/time, I will call
____________ at ______________________ to change the visit. If I do not call in time to change the visit, I
know that I may have to go to ____________ between __________ for my DOT visit.
6. I will notify the health department if I am unable to take my medication for any reason.
7. The side effects of the medication I am taking have been explained to me. I agree to call the health
department at ___________________ immediately if I develop any of these side effects.
8. I agree to tell the health department if I move or change my phone number. I agree to tell the health
department how to reach me in person and by telephone.
9. My treatment plan has been explained to me and all my questions have been answered. I have a copy of
this plan.
___________________________________
__________________________________________________
Client’s Signature
Date
Public Health Representative/Title Signature
Date
___________________________________
Witness/Interpreter’s Signature
Date
Affix Patient label or complete:
Name
_____________________________________________
Address _____________________________________________
_____________________________________________
City, State, Zip ________________________________________
Telephone ____________________________________________
Patient ID# ___________________________________________
GA DPH TB Unit
Form 603.LTBI (3/2015)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form Tb-101 - Latent Tuberculosis Infection Record - West Virginia Department Of Health And Human Resources
Legal
Form Et 13 - Application For Consent To Transfer The Proceeds Of Insurance Contracts, Employer Death Benefi Ts And Retirement Plans For Resident And Nonresident Decedents
Financial
Form Et 13 - Application For Consent To Transfer The Proceeds Of Insurance Contracts, Employer Death Benefi Ts And Retirement Plans For Resident And Nonresident Decedents (ohio Revised Code 5731.39)
Financial
Form Et 13 - Application For Consent To Transfer The Proceeds Of Insurance Contracts, Employer Death Benefits And Retirement Plans For Resident And Nonresident Decedents
Financial
Related Categories
Parent category: Business