Interjurisdictional Tb Notification (Ijn) Form - National Tuberculosis Nurse Coalition Page 3
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1
2
3Referred
DOB
Person’s Name
SECTION 5:
TB Treatment Summary
Current Treatment Summary for:
Therapy
Drug
Dosage
Date Started
Admin
Therapy
Drug
Dosage
Date Started
Admin
Therapy
Drug
Dosage
Date Started
Admin
Therapy
Drug
Dosage
Date Started
Admin
Therapy
Drug
Dosage
Date Started
Admin
Therapy
Drug
Dosage
Date Started
Admin
Estimated Date
Last DOT dose administered on:
# of doses given for travel
of Completion
Prescription
MAR/DOT
Side Effects or Adherence Problems
Given
Log Attached
Comments:
Note: This form contains confidential patient information. Please comply with HIPAA regulations when sending this form.
Interjurisdictional TB Notification Form (IJN)
Revision: May 2015
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