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Virginia Department of Health TB Intake Sheet Revision # ICD9# Last Name First Name Middle Birth Date / / Race Sex Marital status Parent/Guardian Home Address Apt # City State Zip Home Phone Work

How to fill out tb contact registration application

How to fill out the TB contact registration application:

1. Obtain the application form: You can request the application form from your local health department or download it from their website. Make sure you have the most recent version of the form.
2. Fill in personal information: Provide your full name, address, phone number, and date of birth in the designated fields. Double-check the accuracy of the information as it will be used for communication and record-keeping purposes.
3. Provide contact details: Include the contact details of the person or facility responsible for your TB care, such as the name, address, and phone number of your healthcare provider or clinic.
4. Answer questions about TB exposure: The application will likely ask if you have been in contact with someone diagnosed with tuberculosis (TB) in the past. If yes, provide details about the contact, such as the person's name, relationship to you, and the dates of exposure.
5. Medical history: Some applications may require you to provide your medical history, including any previous TB diagnoses or treatments. Fill in this section accurately and provide relevant information to the best of your knowledge.
6. Consent and signature: Read through the provided consent section carefully, and if you agree to the terms, sign and date the application form. Your signature confirms that the information provided is accurate and that you authorize its use for the purpose of TB contact registration.
7. Submit the application: Once the form is complete, follow the instructions provided to submit the application. This may involve mailing it to the designated address or delivering it in person to a specific office.

Who needs the TB contact registration application?

1. Individuals with known exposure to TB: Anyone who has been in close contact with someone diagnosed with TB needs to fill out the contact registration application. This applies to family members, friends, coworkers, or anyone who has spent a significant amount of time with an infectious TB patient.
2. Healthcare workers: Healthcare professionals who have been in contact with TB patients during the course of their work, such as doctors, nurses, and laboratory staff, may also need to complete the TB contact registration application.
3. Institutions and organizations: Institutions or organizations where TB exposure has occurred, such as schools, prisons, or shelters, may be required to register contacts to ensure proper management and surveillance of TB cases.

Remember, the specific requirements for the TB contact registration application may vary depending on your location and local health regulations. It is important to follow the instructions provided on the application form and consult with your healthcare provider or local health department if you have any questions or need further guidance.

For pdfFiller’s FAQs

What is tb contact registration application?

The TB contact registration application is a form used to register individuals who have been in contact with someone diagnosed with tuberculosis.

Who is required to file tb contact registration application?

Healthcare providers and public health agencies are required to file the TB contact registration application.

How to fill out tb contact registration application?

The TB contact registration application can be filled out online or on paper, and it requires information about the individual's contact with the TB patient.

What is the purpose of tb contact registration application?

The purpose of the TB contact registration application is to track and monitor individuals who may have been exposed to tuberculosis in order to prevent the spread of the disease.

What information must be reported on tb contact registration application?

The TB contact registration application requires information about the individual's name, contact information, relationship to the TB patient, and any symptoms they may be experiencing.

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