Forms

New Hawaii Administrative Rules (HAR 11-164.2) Manual

Chapter 11-164.2 of the Hawaii Administrative Rules has been signed by Governor Ige, and will be in effect as of Monday, March 19, 2018. This manual is posted with a table of new resource documents on page 11 and new forms on pages 12 thru 43, per of HAR 11-164.2, (Eff. 3/17/2018) Hawaii TB Clearance Manual (10-30-17)

Hawaii TB Clearance Manual (10-30-17)

Forms for the Public

Registration FormIf you need a tuberculin skin test or chest X-ray to comply with state TB clearance requirements, fill out (both sides) of this registration form and bring it with you to a DOH testing location to save time.

TB-1-Registration-Form-Rev.-2_21_18


 

Forms for Health Care Providers, Facilities, and Institutions

Reporting Forms: If you are a health care provider or facility reporting a suspected or confirmed TB case, fill out the Notifiable Disease Report for Tuberculosis form and fax to TB Registry at 832-5624.
– Notifiable Disease Report for Tuberculosis (Rev. 1/09)
Tuberculosis Case Follow-Up Report (Rev. 5/10)

Reporting Guidance
Notifiable Disease Report for Tuberculosis: Definitions and Instructions (Rev. 1/09)
Reporting Requirements for Suspected or Confirmed Tuberculosis (Rev. 1/09)


Tuberculosis Risk Assessment Form
If you are a health care provider, this is the department-approved form to assess for TB risk, per HAR 11-164.2 (Eff. 3/17/2018).
TB Document G  TB Risk Assessment for Adults and Children

Tuberculosis Symptoms Screening Form
If you are a health care provider, this is the department-approved form to screen for signs and symptoms of TB disease, per HAR 11-164.2 (Eff. 3/17/2018).
– TB Document H  TB Symptom Screen

This page last updated:  April 3, 2018