New Jersey Department of Health

TB Services

PO Box 363, Trenton, NJ 08625-0363	MEDICATION REQUEST ORDER
Agency Name

Reporting Period

From:	To:
Shipping Address

City

State

Zip Code

MEDICATION	BEGINNING INVENTORY	AMOUNT DISPENSED	EXPIRED, LOST, OR DESTROYED	ENDING INVENTORY	AMOUNT REQUESTED	AMOUNT SHIPPED
Avelox (Moxifloxacin)

400 mg / 30 per bottle
B-6 (Pyridoxine)

50 mg / 100 per bottle
Biaxin (Clarithromycin)

250 mg / 60 per bottle
Biaxin (Clarithromycin)

500 mg / 60 per bottle
Capreomycin (Capastat)

10 ml / 1 gram vial
Cipro (Ciprofloxacin)

500 mg / 100 per bottle
Cycloserine (Seromycin)

250 mg / 30 capsules per box
Ethambutol (Myambutol)

100 mg / 100 per bottle
Ethambutol (Myambutol)

400 mg / 100 per bottle
Ethionamide (Trecator)

250 mg / 100 per bottle
Isoniazid (INH)

100 mg / 100 per bottle
Isoniazid (INH)

300 mg / 30 per bottle
Isoniazid (INH)

Syrup 473 ml / 16 oz. bottle
Levaquin (Levofloxacin)

250 mg / 50 per bottle
Levaquin (Levofloxacin)

500 mg / 50 per bottle
Linezolid (Zyvox)

600 mg, 20 per bottle
Ofloxacin (Floxin)

400 mg, 100 per bottle
Paser

4 gram / 1 dose packet (30 packets per box)
PPD

1 ml, 10 test vial
PPD

5 ml, 50 test vial
Pyrazinamide (PZA)

500 mg / 100 per bottle
Rifabutin (Mycobutin)

150 mg / 100 per bottle
Rifampin (Rifadin)

150 mg / 30 per bottle
Rifampin (Rifadin)

300 mg / 60 per bottle
Rifamate (Isoniazid and Rifampin)

300 mg–Rifampin, 150mg-INH / 60 per bottle
Rifapentine

32 tablets per box (Four 8-tablet pouches)
Rifater (Isoniazid, Rifampin, and Pyrazinamide)

120 mg-Rif, 50mg-INH, 300 mg-PZA / 60 per btl
Sterile Water

10 ml, 10 cc vial
Syringes (PPD Syringes)

26 g, 3/8 needle, 1 cc
Syringes (1M Injection)

22 g, 1-1/2 needle, 3 cc
Requested By (Print)

Signature

Phone Number

Date

TB-3

MAR 16	FOR STATE USE ONLY	Approved to Ship	Order No.	Shipped By	Date Shipped

TB-3, Medication Request Order

TB-3, tuberculosis, medication request, order, drugs, TB Services, TB

ewhite

2014-06-27

NJDOH