Draft HR TB Screening Form

Tuberculosis (TB) Risk Assessment Questionnaire

To satisfy job-related requirements in the California Education Code, Sections 49406 and 87408.6 and the California Health and Safety Code,Sections 1597.055, 121525, 121545 and 121555.
Instructions:

Please complete and electronically sign. A district healthcare provider will review your information and will contact you with any next steps (if required).
Employee Name*

First Name Last Name
Date of Birth*

MonthDay Year
Date
Employee Type*

New Hire from Human ResourcesOn-going Employee (Re-screen due per Human Resources)
If a new hire, what is the name of the HR staff or department/school staff member you are currently working with?
District Employee ID # (if applicable)
Contact Phone #*
Please enter a valid phone number.
Email Address where you can be contacted (if current employee use your @sanjuan.edu)*
example@example.com
Job Title*
School/Department/Location Name*
1. Do you have a history of Tuberculosis (TB) disease or infection?*

YesNo
2. Have you ever had a TB test that required follow-up evaluation?*

YesNo
3. Have you ever been treated for TB?*

YesNo
If you have answered "Yes" to any of the questions above, please STOP HERE, skip the remaining questions and sign/date below. If you answered "No" to all questions above, please proceed to questions #4-7.
4. Have you ever been in close contact with someone who has had infectious TB?

YesNo
If yes, please describe approximately when and for how long?
5. Do you have one or more symptoms of TB (see below) that cannot be attributed to another health condition?

YesNo
If Yes, please check all that apply

Prolonged coughCoughing up bloodExtreme weight lossExcessive feverUnexplained fatigueNight sweats
6. Were you born in the United States, Canada, Australia, New Zealand, Western Europe or Northern Europe?

YesNo
If you answered "No", then what country were you born in and how long have you lived in the United States?
7. Have you ever visited a country located outside of the United States, Canada, Australia, New Zealand, Western Europe or Northern Europe for longer than 1 month?

YesNo
If you answered "Yes", then please describe what country/countries and approximate date(s) of travel?
Today's Date*

MonthDay Year
Date
Applicant/Employee verifies that the answers provided are true and factual:*

Clear
Should be Empty:

Tuberculosis (TB) Risk Assessment Questionnaire

Instructions:

If you have answered "Yes" to any of the questions above, please STOP HERE, skip the remaining questions and sign/date below. If you answered "No" to all questions above, please proceed to questions #4-7.