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First Name:        Last name:

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How would you characterize your organization?

State/City/County Hospital State/City/County Health Department Drug Treatment Facility Correctional Institution Community Based Organization Private Hospital Nursing Home Private Provider Clinic Other Select the Organization

What percentage of time do you spend on TB-related issues?

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Below are the materials you are ordering. Please indicate the number of items you wish:

	With Revised Guidelines for RIF-PZA
Pocket Reference Cards Laminated (5.5" x 4.25") or Clinic Posters (13" x 19.5")
	Treatment of Latent Tuberculosis Infection (LTBI)	Treatment of Latent Tuberculosis Infection (LTBI) in Children and Adolscents	Treatment of Latent Tuberculosis Infection (LTBI) in Pregnancy/ Postpartum
	Pocket Reference Cards No. of copies:	Pocket Reference Cards No. of copies:	Pocket Reference Cards No. of copies:
	Posters --------------- - No. of copies:	Posters --------------- - No. of copies:	Posters --------------- - No. of copies:
	Tuberculin Skin Test: Pediatric and Adolescent Risk Assessment Questionnaire (Poster)	Screening Children & Adolescents for LTBI (5.5" x 4.25" Card)
	Posters --------------- - No. of copies:	Pocket Reference Cards No. of copies:

Training Booklets (8.5" x 11")
	Targeted Tuberculin Skin Testing and Treatment of Latent Tuberculosis Infection in Children and Adolescents		Improving LTBI Completion Rates for Pediatric Patients: A Managers Guide (Booklet)		Pediatric Calendar for LTBI Completion (Booklet) Limit 10 per order				Addressing HIV/AIDS Issues in TB Contact Investigation: A Guide for Contact Investigators, Managers and Trainers
	(24 Pages)		(58 Pages)						(50 pages)
	No. of Copies		No. of copies:		No. of copies:				No. of copies:
	Peer Support for LTBI Treatment Adherence: A Manual for Program Managers and Supervisors of Peer Workers		Strategies for Involving International Medical Graduates in TB Control Activities		Latent Tuberculosis Infection: Seven Case Studies				Improving Treatment Completion for Latent Tuberculosis Infection Among Health Care Workers
	(59 pages)		(45 pages)		(101 pages)			(30 pages)
	No. of copies:		No. of copies:		No. of copies:				No. of copies:

	Social Support Services for Tuberculosis Clients		Tuberculosis: Six Case Studies
	(26 pages)		(82 pages)
	No. of copies:		No. of copies:

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