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Douglas A. Ducey | Governor Cara M. Christ, MD, MS | Director 150 North 18th Avenue, Suite 500, Phoenix, AZ 85007-3247 P | 602-542-1025 F | 602-542-1062 W | azhealth.gov Health and Wellness for all Arizonans TUBERCULOSIS CONTROL – INCENTIVE PROGRAM – INCENTIVE REQUEST SUBMIT THIS FORM to the Arizona Department of Health Services (ADHS) Tuberculosis (TB) Control Program by fax (602) 364-3267 or email kara.tarter@azdhs.gov. If you have any questions regarding this form, please call (602) 364- 4750. Bashas’ Walmart Chevron Total number of $10.00 vouchers requested Total value ($) of vouchers requested The vouchers will be used solely as incentives for clients receiving anti-TB treatment. Active cases of TB will have the highest priority; however, if warranted these vouchers can be offered to high-risk contacts, particularly children receiving treatment for LTBI. Initials of program representative: The program will keep a record (tracking log) of every voucher dispensed and record the name of recipient, DOB, TB case/infected contact/high risk person with LTBI, contact information, date. Initials of program representative: The program will submit a monthly report to ADHS listing the number of vouchers distributed, the number of patients who received vouchers, and number of vouchers distributed YTD. Initials of program representative: Comments: Program Representative Contact Name, phone#, email Director or DON Contact Name, phone#, email Physical Address Where Cards Should be Sent (Cannot be a PO Box): _____________________________________________________ ________________________ Signature of Program Representative Date _____________________________________________________ ________________________ Signature of Director or DON Date Date received by ADHS: __________________ 500 100 CLV CLV CLV Corinne Velasquez, 602 506-6657, corinne.velasquez@maricopa.gov Corinne Velasquez, 602 506-6657, corinne.velasquez@maricopa.gov 1645 E. Roosevelt Phoenix, AZ 85006 Attn: Corinne 8/24/2020 8/24/2020 FOR COUNTY: _______________________________________ Clint Hickman, Chairman Date Board of Supervisors APPROVED AS TO FORM: _________________________________________ Attorney for County Date ATTEST: _________________________________________ Office of the Clerk of the Board Date