Number requested: (available online only)
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Product Order Form INSTRUCTIONS: Please complete both pages and send to:
Alysi a Wayne Heartland National TB Center · 2303 SE Military Drive · San Antonio, TX 78223
PH: (800) 839-5 864 FAX: (210) 531-4590 [email protected]
A.) TB in the Community: Educational Flipchart facilitating work in the border regions; each chart is in English and Spanish.
Number requested: ________________ (maximum order is 2; contents contain both English and Spanish sections)
B.) BMI Chart: Impact of poor nutrition on TB relapse – 6.33" W x 13.58" H (tri-fold)
Number requested: (available online only)
C.) Impacto de la Mala Nutrición en la Recaída de TB (BMI Chart SPANISH) – 6.33 “ W x 13.58” H (tri-fold)
Number requested: (available online only)
D.) Beyond Diversity: A journey to cultural proficiency – a facilitator guide used to build internal capacity within TB programs.
Number requested: _________________ (maximum order is 10)
E.) Calipers for measuring TST reactions
Number requested: _________________ (maximum order is 25)
F.) Clinicians Guide to the TB Laboratory
Number requested: _________________(maximum order is 2)
G.) Case Studies in Tuberculosis: Nurse Case Managment Training Tools for Patient Success - a collection of nurse case studies and
accompanying tools. (CNE Credit Available)
Number requested: _________________(maximum order is 2)
H.) Characteristics of Second-Line Drugs for MDR-TB
Number requested: _________________(maximum order is 25)
I.) Evaluation of a Pregnant Patient at Risk for TB - 1 page flow diagram for clinicans and healthcare providers.
Number requested: (resource unavailable)
J.) Guidelines for Home and Hospital Isolation of Infectious Tuberculosis Patients
Number requested: _________________ (maximum order is 25)
K.) Injectable Administration – 2 page teaching sheet for clinicians and healthcare providers covering Amikacin, Capreomycin OR Streptomycin
Amikacin requested: _____________ Capreomycin requested: _____________ Streptomycin requested: _____________
L.) Limiting Liver Toxicity in the HIV-Positive Patient with Latent Tuberculosis Infection
Number requested: (available online only)
M.) Management of the Active TB Patient at Risk of Hepatotoxicity – 1 page flow diagram for clinicians and healthcare providers.
Number requested: _________________(maximum order is 25)
N.) Mental Health Assessment Tool
Number requested: ________________(maximum order is 10)
O.) MDR TB Care Plan – 1 page diagram for clinicians and healthcare providers.
Number requested: (resource unavailable)
P.) Plan de Cuidado para el Paciente con TB Multifármaco Resistente (MDR TB Care Plan in SPANISH)
Number requested: (resource unavailable)
Q.) Model Tuberculosis Prevention Program for College Campuses – manual for local or college health care healthcare providers.
R.) Pediatric TB Radiology for Clinicians – shows and describes examples of radiographic abnormalities common in pediatric tuberculosis, emphasizing pulmonary, lymphatic and meningeal disease.
Number requested: (available online only)
S.) Revised Tuberculosis Treatment Guidelines (2003) – 1 page poster for clinicians or healthcare providers.
Number requested: (resource unavailable)
T.) Rifamycins and Anti-Diabetic Agents: Drug-Drug Interactions - 2-sided diagram for clinicians and healthcare providers that describes drug-drug interactions of Rifamycins and anti-diabetic agents.
Number requested: ________________ (maximum order is 25)
U.) Rifamycins and Cardiovascular Agents: Drug-Drug Interactions - 2-sided diagram for clinicians and healthcare providers that describes drug-drug interactions of Rifamycins and cardiovascular agents.
Number requested: ________________ (maximum order is 25)
V.) Rifamycins and Psychotropic Drugs: Drug-Drug Interactions - 2-sided diagram for clinicians and healthcare providers that describes drug-drug interactions of Rifamycins and psychotropic drugs.
Number requested: ________________ (maximum order is 25)
W.) TB Core Reference Set for Clinicians – CD-ROM with comprehensive list of reference materials.
Number requested: (resource under review)
X.) TB at a Glance: A reference for practitioners on basic tuberculosis information - pocket size booklet that provides basic information on the
diagnosis and treatment of TB.
Number requested: (resource unavailable)
Y.) Tuberculosis Adverse Drug Events – 4 x 5 pocket guide for healthcare providers.
Number requested: (product under review; resource is available online)
Z.) Tuberculosis Medication Drug and Food Interactions – 4 x 5 pocket guide for healthcare providers.
Number requested: (product under review; resource is available online)
AA.) Tuberculosis Treatment Guidelines (2016) - 4 x 5 pocket guide for healthcare providers.
Number requested: _________________ (maximum order is 10)
BB.) Tumor Necrosis Factor-Alpha (TNF-Alpha) Antagonists and the Increased Risk of Tuberculosis
Number requested: _________________ (maximum order is 25)
CC.) TB Testing in Children Number requested: (resource available online only)
Mailing and Contact Information Name:
Discipline (RN, BSN, etc.):
Job Title:
Agency:
Address 1, Address 2:
City, State/Province, Zip:
Country:
Phone: ( ) — Ext.
Fax: ( ) —
Email: Additional Notes: If requesting more than maximum single order, please provide justification.
QUESTIONS ABOUT HNTC PRODUCTS? NEED MORE THAN THE MAXIMUM? Please contact Alysia Wayne at 1-800-839-5864 or [email protected]
If needed by a specific date, please contact Alysia.
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