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 (9-06-24)

Hawaii TB Clearance Manual (9-06-2024)

Forms for the Public

Registration Form:  If 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.

Blank pdf form (manually fill out):  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 (NDR) Form (Rev. 1/16)
– Tuberculosis Case Follow-Up Report (Rev. 5/10)

Reporting Guidance
– Notifiable Disease Report (NDR) Form: Definition & Instructions (Rev. 1/16)
– 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: September 23, 2020