TB risk assessment form - volunteer annual ed.

Tuberculosis Risk Assessment and Symptom Evaluation
EMPLOYEE NAME *
DATE *

Month Day Year
Date
*

I am a new employee onboarding I am an employee filling this risk assessment out as part of annual review

TB History
Have you ever been diagnosed with active TB disease *

YES NO
Have you ever been diagnosed with latent TB infection or had a positive skin test or a positive blood test for TB? *

YES, one or more of these is true for me NO, none of these is true for me
Have you ever been treated with medication for TB or for a positive TB test (ie.g., taken "INH")? *

Yes No
If yes to the above question, what year, with which medication, for how long and did you complete the treatment course
TB Vaccination Status
Have you ever been vaccinated with BCG (i.e., TB vaccination)? *

YES NO

TB Risk Factors
Do you have a history of temporary or permanent residence (> 1 month) in a country with a high TB rate (i.e. any country other than Australia, Canada, New Zealand, United States, and those in western or Northern Europe)? *

YES, I have been in a foreign country for 30 days or more (not including those listed above) NO, I have never been in a foreign country for 30 days or more (any country other than listed above).
If you checked yes to the above question, please pick one of the following:

I am onboarding and this is first time I am completing Hospicare's TB risk assessment I am filling this out as part of annual review, and this IS NEW since the last risk assessment I am filling this out as part of annual review, and this is NOT NEW since the last risk assessment
Have you had close contact with anyone who had active TB since your last TB test: *

YES NO
Do you have a weakened immune system for any reason including organ transplant, recent chemotherapy, poorly controlled diabetes, HIV infection, cancer, or treatment with steroids for more than 1 month, immune-suppressing medications such as a TNF-alpha antagonist or another *

YES NO

*

As a Hospicare staff member, volunteer, or contracted employee, I attest to answering these questions accurately and by checking this box and signing my name below, I am electronically signing this form.
Employee Signature *

Clear
Print name *
Date *

Month Day Year
Date
Should be Empty: