North Dakota Department of Health TB SURVEILLANCE Att: Division of Disease Control 2635 East Main Avenue Bismarck, North Dakota 58506-5520 REQUEST FOR REIMBURSEMENT Agency Name Address City, State, Zip State Vendor # Contract # Billing Period EXPENDITURES THIS CUMULATIVE TO DATE BUDGET CATEGORY PERIOD EXPENDITURES APPROVED BUDGET Tuberculin Skin Test - Placement/Reading Results Infection - Medication Latent TB - - Administration, Client Education and Other Follow-Up - - Travel for Targeted Testing and Treatment Activities - - Supplies - - TOTAL $ - $ - $ - Less Previous Request for Reimbursements Submitted Balance Due $ - I certify that this request accurately reflects expenditures in accordance with an agreement between the above agency and the North Dakota Department of Health. I understand all supporting documents will be kept on file and available for audit. Agency Approval____________________________________________Date_________________ Telephone_____________ ND Department of Health Approval: Program Director_____________________________________ Date ____________________________ Director Disease Control_______________________________ Date ____________________________ Amount Speed chart Account Dept Project ID Comments 2039__45 623140 2201 HLH0390__ TB -Med Fees $ Total Reimbursement Voucher ID Date Acctg Approval SFN 8684 TB SURV 1_2011 Total # of Reimbursement Expenditures Expenditures Cumulative to date Type of Service Provided Hours/Miles Rate this Period Prior Period Expenditures Tuberculin Skin Test - Placement/Reading Results $20 - - Latent TB Infection - Medication Administration, Client Education and Other Follow-Up $20 - - Travel for Targeted Testing and Treatment Activities $0.510 - - Supplies (list items below and include a copy of the invoice) Actual Cost - Total - - - List Supplies: TB Surveillance contract sites must provide the following information on targeted TB testing and treatment activities supported with TB Program funds. This Quarter Cumulative (1) Number of clients at risk for TB disease who received a tuberculin skin test this quarter. (2) Number of these clients identified with latent TB infection. (3) Number of clients with latent TB infection that were prescribed treatment. (4) Number of clients with latent TB infection that completed a course of treatment.
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