Interjurisdictional Tb Notification (Ijn) Form - National Tuberculosis Nurse Coalition

Download a blank fillable Interjurisdictional Tb Notification (Ijn) Form - National Tuberculosis Nurse Coalition in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Interjurisdictional Tb Notification (Ijn) Form - National Tuberculosis Nurse Coalition with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

ADVERTISEMENT

Interjurisdictional TB Notification (IJN) Form
Type of Referral:
Active/Suspect TB
Date of Expected Arrival
- See Section 1
TB Contact
- See Section 2
Class A/B
- See Section 3
Online directory of state and big city TB programs:
TB Infection
- See Section 4
/community/statecityterritory/
Referring Jurisdiction Information:
City
County
State
Person
Email
Completing Form
Phone
Fax
Form Sent to:
Date
IJN Form Sent
Name
Phone
Fax
Location
Name
Phone
Fax
Location
Return Follow-Up Form To:
Follow Up
Requested
Name
Jurisdiction
Location
Phone
Fax
Referred Person’s Information:
Middle
Last Name
First Name
AKA
Initial
DOB
Sex
Hispanic
Race/Ethnicity
Country of Birth
Primary Language
Interpreter Needed?
New Address:
#/St/Apt
City
State
Zip
Phone 1
Type
Phone 2
Type
Alternate
Phone
Email
Contact Name
National Tuberculosis Nurse Coalition (NTNC)
National Tuberculosis Controllers Association (NTCA)
/resources/interjurisdictional-transfers
Revision: May 2015

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Medical
Go
Page of 3