St. Anselm School - TB Questionnaire

California School Employee Tuberculosis Risk Assessment Questionnaire

(for pre-K, K-12 schools and community college employees, volunteers and contractors)
- Use of this questionnaire is required by California Education Code sections 49406 and 87408.6, and Health and Safety Code sections 1597 .055 and 121525-121555.
- The purpose of this tool is to identify adults with infectious tuberculosis (TB) to prevent them from spreading disease.
- Do not repeat testing unless there are new risk factors since the last negative test.
- Do not treat for latent TB infection (LTBI) until active TB disease has been excluded: Fof individuals with signs Of symptoms of TB disease Of abnofmal chest x-,ay consistent with TB disease, evaluate for active TB disease with a chest x-,ay, symptom scfeen, and if indicated, sputum AFB smeafs, cultufes and nucleic acid amplification testing. A negative tubefculin skin test (TST) o, intefferon gamma felease assay (IGRA) does not rule out active TB disease.
Name of Person Assessed for TB Risk Factors:

First NameLast Name
Email*
example@example.com
Assessment Date:

MonthDayYear
Date
Date of Birth:

MonthDayYear
Date
History of Tuberculosis Disease or Infection (Check appropriate box below)

YesNo (Assess for Risk Factors for Tuberculosis using box below)
If there is a documented history of positive TB test or TB disease. then a symptom review and chest x-ray (if none performed in the previous 6 months) should be performed at initial hire by a physician, physician assistant, or nurse practitioner. If the x-,ay does not have evidence of TB. the person is no longer required to submit to a TB risk assessment or repeat chest x-rays.
TB testing is recommended if any of the 3 boxes below are checked

One or more sign(s) or symptom(s) of TB disease (TB symptoms include prolonged cough, coughing up blood, fever, night sweats, weight loss, or excessive fatigue.)Birth, travel, or residence in a country with an elevated TB rate for at least 1 month (1) Includes countries other than the United States, Canada, Australia. New Zealand, or Western and North European countries. (2) Interferon gamma release assay (IGRA) is prefel'l'ed over tuberculin skin test (TST) for non-US-born persons.)Close contact to someone with infectious TB disease during lifetime
Should be Empty:

California School Employee Tuberculosis Risk Assessment Questionnaire