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ARIZONA DEPARTMENT OF HEALTH SERVICES PREPAREDNESS 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. lfyou have any questions regarding this form, please call (602) 364-4750, Bashas' Walmart Chevron Total number of $10,00 vouchers requested 50 Total value ($) of vouchers requested $500.00 ' The vouchers will be used solely as incentives for clients receiving anti-TB treatment. Initials of program Active cases of TB will have the highest priority; however, if warranted these vouchers representative: can be offered to high-risk contacts, particularly children receiving treatment for L TBL cvhb The program will keep a record (tracking log) of every voucher dispensed and record Initials of program the name of recipient, DOB, TB case/infected contact/high risk person with LTBI, representative: contact information, date, cvhb The program will submit a monthly report to ADHS listing the number of vouchers Initials of program distributed, the number of patients who received vouchers, and number of vouchers representative: distributed YTD, cvhb Comments: Program Representative Contact Charlotte Hunter-Brown Name, phone#, email Director or DON Contact Corinne Velasquez 602-506-6657 corinne,velasquez@maricopa,gov Name, phone#, email Physical Address Where Cards Should 1645 E, Roosevelt St Phoenix AZ 85006 be Sent (Cannot be a PO Box): Charlotte V. Hunter-Brown OlgitoUy signed hy C/lai!ollo V. Hunler•Brcr;n Oale: 2021.09.1007:39.50 --OTOO' Signature of Program Representative Corinne Velasquez Signature of Director or DON Oigila!y signed by CoMoo Vclasqooz Dale: 2021.09.10 10:41:5e -0roo· Date Date Date received by ADHS: _______ _ Douglas A. Ducey I Governor Cara M. Christ, MD, MS I Director 150 North 18th Avenue, Suite 500, Phoenix, AZ 85007-3247 P I 602-542-1025 F I 602-542-1062 W I azhealth,gov Health and Wellness for all Arizonans