Request for Medication to Treat Latent TB Infection (LTBI)
Tuberculosis (TB) Prevention and Control Program
P.O. Box 64975
St. Paul, MN 55164-0975
Phone: (651) 201-5414 Fax: (651) 201-5500
1. Patient: PLEASE PRINT CLEARLY
____________________________________________________
Name (last, first, MI)
____________________________________________________
Street address
____________________________________________________
City
State
Zip
____________________________________________________
County
Today’s Date:
/
/
2. Birth date: ____/____/______
3. Sex:
male
female
4. Country of origin:
United States
other: ______________
Phone
5. Health care provider:
_______________________________________
Name (first, last, degree, i.e. MD, DO, NP, PA)
(_____)_________________________________
Phone
(_____)_________________________________
Fax
8. Chest X-ray date: ______/______/________
CXR should be done ≤ 6 months before treatment is
started (≤ 3 months for high risk [i.e., young child,
new converter, immunocompromised, prior abnormal
CXR, or other risk factors]).
_______________________________________
Result:
Clinic
_______________________________________
normal (negative for active TB)
Street address
_______________________________________
abnormal but not consistent with active TB
City
other (please include copy of report)
State
Zip
6. Indication for TB screening:
foreign-born from high-prevalence area
9. Has clinician ruled out active TB disease?
CXR indicating stable, inactive TB
Yes (i.e., CXR negative for active TB and no TB-
recent contact to known infectious active TB
related symptoms or physical findings. To prevent
the development of drug-resistant TB, LTBI
treatment should not be started until active TB
disease has been ruled out. Report suspected
active TB disease to MDH at 651-201-5414 or
1-877-676-5414).
medical condition
(e.g., HIV-infected, organ transplant, diabetes
substance abuse, immunosuppression)
correctional facility inmate
nursing home resident
drug treatment facility resident
homeless
10. Additional questions:
migrant worker
a. Does the patient have any drug allergies?
No
Yes - please specify: _______________
employee screening
______________________________________
other:_________________________________
7. Tuberculin skin test date: ____/____/_____
Result:
positive* (______mm#)
negative
and/or
IGRA (TB blood) test date: ____/____/_____
Result:
positive
negative
indeterminate
b. Does the patient have a chronic medical condition?
No
Yes - please specify: _______________
______________________________________
c. Is the patient currently taking any prescription or
non-prescription drugs?
No
Yes - please specify or attach sheet:
* Interpretation depends on the person’s risk factors for TB
#
Measure crosswise axis of forearm, record mm induration
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______________________________________
______________________________________
11. Medication(s) requested:
Patient’s weight: ________ lbs/kg (required for children & adults dosed < maximum per CDC guidelines)
Length of
Start Date: (needed if patient has already
started
treatment)
Drug
Dosage
Frequency
Regimen
(mos.)
Isoniazid (INH)
Other:
Rationale for alternative regimen:
For INH requests only: Vitamin B6:
Vitamin B6 supplementation to prevent neuropathy is
not routinely recommended. MDH will supply Vitamin
B6 if clinically indicated. Check box(es) at right.
25 mg. daily
50 mg. daily
Indication for Vitamin B6 (pyridoxine):
diabetes
malnutrition
breastfeeding
renal failure
HIV infection
pregnancy
seizure disorder
alcoholism
infant who is > 50% breastfed and taking INH;
recommended Vitamin B6 dose: 6.25 mg daily
I have attached the signed prescription(s) (REQUIRED).
Please label the medication bottle in Spanish.
12. Send medications to: (must be a health care provider licensed to administer medications):
Name: ________________________________________________
Same as provider (#6)
Clinic/Agency: __________________________________________
Address: ______________________________________________
______________________________________________
Phone: (_____) _________________________________________
You will receive the first month’s supply of medication within 5 working days of request.
After treatment starts, complete & return the start date verification form included in the initial shipment.
Upon receiving this verification, MDH will ship refills monthly until treatment is complete.
Unused medication cannot be returned to MDH or the pharmacy. If treatment is discontinued for any
reason or patient is lost to follow-up, please contact MDH ASAP to stop shipments.
LTBI treatment guidelines (http://www.cdc.gov/mmwr/PDF/rr/rr4906.pdf) recommend monthly
monitoring by a health care provider throughout treatment to evaluate for adverse drug effects,
signs/symptoms of active TB and patient adherence. A suggested LTBI monitoring flow sheet is
available at http://www.health.state.mn.us/divs/idepc/diseases/tb/medications.html
13. Form completed by:
Same as provider (#6)
Name: ________________________________________________
Agency: _______________________________________________
Same as “send to” (#12) Phone: (_____) _________________ (please provide direct line if possible)
Form has been reviewed for completeness (Note: forms will be returned to the requestor if
incomplete or if signed prescription is missing. This will delay processing your request.)
Notes: _________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
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Revised, May 2012