SIG' BLOCK _ INCENTIVE REQUEST 091021.PDF

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 tb@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: __________________ 
For County: 
_____________________________ 
Jack Sellers, Chairman, BOS  Date
APPROVED AS TO FORM: _______________________ 
                                             Attorney for County,         Date
ATTEST: _______________________ 
               Clerk of the Board
Date
200
200
$2000.00
$2000.00
cvhb
cvhb
cvhb
Charlotte Hunter-Brown
Corinne Velasquez 602-506-6657 corinne.velasquez@maricopa.gov
1645 E. Roosevelt St. Phoenix AZ 85006
Charlotte V. Hunter-Brown
Digitally signed by Charlotte V. Hunter-Brown 
Date: 2021.09.10 07:39:50 -07'00'
Corinne Velasquez
Digitally signed by Corinne Velasquez 
Date: 2021.09.28 09:40:49 -07'00'
09/28/2021