Form 603 Dot - Directly Observed Therapy (Dot) Agreement For Tuberculosis Treatment printable pdf download

Directly Observed Therapy (DOT)

Agreement for Tuberculosis (TB) Treatment

Name _________________________________________ DOB ______________ Home phone: __________________

Address ___________________________________________________________ Work phone: _________________

City ________________________________________________ ZIP ___________ Cell phone: __________________

Emergency Contact Person _____________________________________ Phone: _____________________________

Health Department _____________________________________________Date: _____________________________

I, ____________________________________________ understand and agree that

(Name of Client)

1. The only way to get well is by taking my TB medicine exactly as my nurse or doctor tells me. If I do not

follow these directions, my illness could come back worse than before. Then it could be harder to treat, take

longer to treat and could spread the disease to others.

2. I will be taking several medications for a long time (6 months or more) in order to kill the TB germs.

3. 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 and get well. In this program, a designated public health employee or a trained

DOT worker is authorized as my agent to maintain possession my medication and to be present when I take

my TB medicine.

4. I will be at: ____ Home ____ Work ____ Clinic/LHD ____ Other (specify) ___________________________

between the hours of _________________ and _______________ for my DOT visit.

5. If I cannot be at the agreed place and time, I will call ________________________________ at

______________________ to change the visit.

6. 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.

7. I will tell my DOT worker if I have any problems. I may be asked to go to ____________________________

to meet with a doctor or nurse and/or to have tests during my treatment.

8. I know that if I miss my visits and do not take my treatment as scheduled, legal action may be taken.

I, ________________________________________________ understand and agree that

(Name of Health Dept./Case Manager)

1. If I cannot be at the agreed place and time, I will call ________________________________ at

______________________ to change the visit.

2. I will keep the client’s health data private.

3. I will answer questions and concerns of the client. I will help link the client to other services as needed.

4. I will promptly tell the doctor or nurse of anything out of the ordinary. I will give reports as needed.

____________________________

___________________________

Client

Nurse

DOT Provider

GA DPH TB Unit

Form 603 DOT (Rev. 12/2011)

Form 603 Dot - Directly Observed Therapy (Dot) Agreement For Tuberculosis Treatment