Form TB-1 "Registration Form" - Hawaii

What Is Form TB-1?

This is a legal form that was released by the Hawaii Department of Health - a government authority operating within Hawaii. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on May 28, 2020;
  • The latest edition provided by the Hawaii Department of Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form TB-1 by clicking the link below or browse more documents and templates provided by the Hawaii Department of Health.

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Download Form TB-1 "Registration Form" - Hawaii

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Hawaii Department of Health - Tuberculosis Control Branch
Date Today:
/
/
Two-Step TST
Month
Day
Year
English
1. Name:
2. Date of Birth:
3. Age:
Last
First
Middle Initial
Maiden Name
4. Sex (at birth):  Male  Female
Home Address:
5. Occupation:
Street Number and Name
Apartment Number / Subdivision
Employer/School:
6. Home Phone: (
)
Work Phone: (
)
City
State
Zip Code
Cell Phone: (
)
Mailing Address:
7. Email:
Street Number and Name
Apartment Number / Subdivision
8. Health Care Provider:
9. Insurance:
City
State
Zip Code
Citizenship:  US Citizen
10. Country of Birth:
11. If not born in US:
12
.
 Immigrant  Refugee
Date arrived to US:
 Other:
13. Preferred language:
Date arrived to HI:
14. Race / Ethnicity: (please check all that apply)
 Amer Indian  Alaska Native  Chinese
 Hispanic  Marshallese  FSMicronesia
 Vietnamese
 Black/African American
 Filipino
 Japanese  Palauan
(Chuuk, Kosrae)  White / Caucasian
 Chamorro (Guam/Saipan)
 Hawaiian  Korean
 Samoan
(Pohnpei, Yap )  Other:
Specify
15. Reason for Tuberculosis screening: (please check one only)
 Food handler
 Health Care Worker
 Day Care / Day Care Employee
 Student
 School Employee
 Foster Parent
 Care / Foster Home Operator
 Contact/Source (PHN: _
 Housing or Shelter Clearance
)
 Care / Foster Home Resident
 Immigration
 Other:
16. Do you have any of these health problems?  Smoking  Kidney Disease/Dialysis
 Diabetes  Cancer (Type:
 None
)
 Yes  No
17. Have you ever stayed at a homeless shelter / jail / prison / nursing home / group home?
18. Were you sent by a health care provider? – If yes, name:
 Yes  No
……………...….…….  Yes  No
19. Have you had a previous positive skin test (swollen) or blood test?
20. Have you taken medicine for Tuberculosis in the past?
.....……………….…….…….
 Yes  No
21. Have you received any immunizations within the past 4 weeks?
…………….…….…
 Yes  No
……………………………….…….…….
 Yes  No
22. FEMALES - ARE YOU PREGNANT?
Please turn this page over and complete your TB Risk Assessment on page 2.
Then sign below to authorize testing, release of medical information, and acknowledgement of understanding:
1. I authorize the Department of Health (DOH) to perform a tuberculin skin test and chest x-ray (if necessary) to the
child (18 years old) named on this form.
2. I authorize DOH to release TB test results and send recommendations to my health care provider.
3. I will return in 48-72 hours for reading of my TB test.
4. I understand that chest x-rays taken at the Tuberculosis Control Branch are interpreted for Tuberculosis Control
purposes only. (Only for TB and not for other diseases.)
5. By signing below, I verify that the information above is true and accurate.
Print Name:
Signature:
Date:
Patient, Parent, Legal Guardian, or Caregiver
Patient, Parent, Legal Guardian, or Caregiver
TB-1 page 1 (Rev 5-28-20)
Hawaii Department of Health - Tuberculosis Control Branch
Date Today:
/
/
Two-Step TST
Month
Day
Year
English
1. Name:
2. Date of Birth:
3. Age:
Last
First
Middle Initial
Maiden Name
4. Sex (at birth):  Male  Female
Home Address:
5. Occupation:
Street Number and Name
Apartment Number / Subdivision
Employer/School:
6. Home Phone: (
)
Work Phone: (
)
City
State
Zip Code
Cell Phone: (
)
Mailing Address:
7. Email:
Street Number and Name
Apartment Number / Subdivision
8. Health Care Provider:
9. Insurance:
City
State
Zip Code
Citizenship:  US Citizen
10. Country of Birth:
11. If not born in US:
12
.
 Immigrant  Refugee
Date arrived to US:
 Other:
13. Preferred language:
Date arrived to HI:
14. Race / Ethnicity: (please check all that apply)
 Amer Indian  Alaska Native  Chinese
 Hispanic  Marshallese  FSMicronesia
 Vietnamese
 Black/African American
 Filipino
 Japanese  Palauan
(Chuuk, Kosrae)  White / Caucasian
 Chamorro (Guam/Saipan)
 Hawaiian  Korean
 Samoan
(Pohnpei, Yap )  Other:
Specify
15. Reason for Tuberculosis screening: (please check one only)
 Food handler
 Health Care Worker
 Day Care / Day Care Employee
 Student
 School Employee
 Foster Parent
 Care / Foster Home Operator
 Contact/Source (PHN: _
 Housing or Shelter Clearance
)
 Care / Foster Home Resident
 Immigration
 Other:
16. Do you have any of these health problems?  Smoking  Kidney Disease/Dialysis
 Diabetes  Cancer (Type:
 None
)
 Yes  No
17. Have you ever stayed at a homeless shelter / jail / prison / nursing home / group home?
18. Were you sent by a health care provider? – If yes, name:
 Yes  No
……………...….…….  Yes  No
19. Have you had a previous positive skin test (swollen) or blood test?
20. Have you taken medicine for Tuberculosis in the past?
.....……………….…….…….
 Yes  No
21. Have you received any immunizations within the past 4 weeks?
…………….…….…
 Yes  No
……………………………….…….…….
 Yes  No
22. FEMALES - ARE YOU PREGNANT?
Please turn this page over and complete your TB Risk Assessment on page 2.
Then sign below to authorize testing, release of medical information, and acknowledgement of understanding:
1. I authorize the Department of Health (DOH) to perform a tuberculin skin test and chest x-ray (if necessary) to the
child (18 years old) named on this form.
2. I authorize DOH to release TB test results and send recommendations to my health care provider.
3. I will return in 48-72 hours for reading of my TB test.
4. I understand that chest x-rays taken at the Tuberculosis Control Branch are interpreted for Tuberculosis Control
purposes only. (Only for TB and not for other diseases.)
5. By signing below, I verify that the information above is true and accurate.
Print Name:
Signature:
Date:
Patient, Parent, Legal Guardian, or Caregiver
Patient, Parent, Legal Guardian, or Caregiver
TB-1 page 1 (Rev 5-28-20)
Hawaii Department of Health - Tuberculosis Control Branch (page 2)
Please complete this TB Risk Assessment for Person Needing Clearance
Yes
No
1. Do you have a cough that has lasted for 3 weeks or longer?
2. Where were you born? ________________________________________
Yes
No
3. In your lifetime, have you traveled or lived outside the United States?
If yes, where and for how long? _________________________________________________
Yes
No
4. At any time, have you been around someone who was sick with TB disease?
(Do not check “Yes” if exposed only to someone with latent TB infection.)
Yes
No
5. Do you have a health problem or do you plan to be on medical treatment that may affect the
immune system? Includes HIV/AIDS, organ transplant, treatment with TNF-alpha antagonist
(ex: Humira, Enbrel, Remicade) or steroid medication for a month or longer.
6. For persons under age 16 only: Is someone in the child’s household from another country?
Yes
No
Which one? _____________________________________
If you need a test, which office will you go to for the test?
Lanakila
EHon
Leeward
Neighbor Island ___________
Other _________________
For office use only:
Primary Assessment:
Issue
Further eval
Initial:
TB ID#:
CC ID#:
Secondary Assess: (Question 1):
Issue
Further eval
Initial:
Prior TST
mm Year:
Coughing up blood
Fever
Night sweats
Unexplained weight loss
Fatigue
Unusual weakness
No symptoms
Tx LTBI?
No
Incomplete
Completed:
_
TST 1: Given:
/
/
Site: LFA / RFA
Initials:
IGRA 1:
Date:
/
/
Result: N / P / I / B
Initials:
Read:
/
/
Result:
mm
Initials:
IGRA 2:
Date:
/
/
Result: N / P / I / B
Initials:
TST 2: Given:
/
/
Site: LFA / RFA
Initials:
(Neighbor Islands) Date of CXR Referral:
/
/
Read:
/
/
Result:
mm
Initials:
PHYSICIAN ASSESSMENT – INITIAL
INITIAL X-RAY
PLAN:
Admit w/u
LTBI Tx
No LTBI
Negative for TB
Possible TB
Follow up:
Abnormal not TB
Unchanged
SURVEY:
Other:
LTBI HiR Letter
PMD Letter
Priority LTBI?  Yes  No
LTBI LoR Letter
Mailed TBC
/
/
Date:
Initials:
:
Other Letter
PHYSICIAN ASSESSMENT – FOLLOW-UP
PLAN:
FOLLOW-UP X-RAY
Admit w/u
LTBI Tx
No LTBI
Negative for TB
Possible TB
Follow up:
Abnormal not TB
Unchanged
SURVEY:
Other:
LTBI HiR Letter
PMD Letter
Priority LTBI?  Yes  No
LTBI LoR Letter
Mailed TBC
/
/
Date:
Initials:
:
Other Letter
TB-1 page 2 (Rev 5-28-20)
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