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S898 ARIZONA DEPARTMENT io OF HEALTH SERVICES ou PREPAREDNESS TUBERCULOSIS CONTROL — INCENTIVE PROGRAM — INCENTIVE REQUEST SUBMIT THIS FORM to the Arizona Department of Health Services (ADHS) Tuberculosis (TB) Control Program by email: tbh@azdhs.gov. If you have any questions, please call (602) 647-3802. + ’ $10 Chevron $100 Walmart Total number of vouchers requested 100 5 ic Qi Total value ($) of vouchers requested $ 1 ,000 $5-000 §1,@oe ‘ im The $10 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. The $100 vouchers will be used solely by the county to acquire enablers for clients receiving anti-TB treatment such as methods of communication, food, toiletry supplies, etc. These should not be given directly to clients. If warranted, these vouchers can be HL used to purchase enablers for high-risk contacts, particularly children receiving treatment for LTBI. ; The program will keep a record (tracking log) of every voucher dispensed and record HL the name of recipient, DOB, TB case/infected contact/high risk person with LTBI; contact information, date, The program will submit to ADHS, as part of the existing quarterly report, the number HL of vouchers distributed, the number of patients who received vouchers, the number of vouchers distributed YTD, and the number of vouchers currently on-hand. Comments: Program Representative Contact oat wae . Ss, 602-376- heidi.lyons .gov Name, Phone, Email Heidi Lyon 6-5966, lyons@maricopa.g Director or DON Contact Michele Castaneda Martinez, 602-525-3866, m.castaneda-martinez@maricopa.gov Name, Phone, Email Physical Address Where Cards Should . Be Sent (Cannot be a PO Box): 1645 E Roosevelt Phoenix, AZ 85006 Heidi Lyons eesti 308 on 9/8/2023 Signature of Program Representative Date Michele Castaneda- *: Digitally signed by Michele . “Castaneda-Martinez Martinez “ “Date: 2023.09.08 18:36:30 -07'00" 9/ 8/ 2023 Signature of Director or DON Date “Su8 lle 1 Ve Date received by ADHS:__' [ea Katie Hobbs | Governor Jennifer Cunico | Director ~~T50 North’ 18th Avenue, Suite 500, Phoenix, AZ 85007-3247 P | 602-542-1025 W | azhealth.gov Health and Wellness for all Arizonans