TB Surveillance by HC120524134447

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									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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