Tuberculosis Screening Questionnaire

TUBERCULOSIS SCREENING QUESTIONNAIRE
Per CDC guidelines and AHC policy, all healthcare personnel should complete this TB symptom screening questionnaire at the time of hire (pre-placement) and annually in their hire month. Occupational Health will reach out to you if further follow up is needed.
Employee Information
Name*

Legal First NameLegal Last Name
Purpose of Questionnaire*

Annual screeningPost-exposure
Date of Birth*

MonthDayYear
Date
Employee ID*
Preferred Phone Number*
Preferred Email Address*
example@example.com
Your primary work location:*
Your Unit/Department*
Questionnaire Date (Today's Date)*

MonthDayYear
Date
Health Care Personnel (HCP) Baseline Individual TB Risk Assessment (CDC)
Temporary or permanent residence of ≥1 month in a country with a high TB rate: Any country other than the United States, Canada, Australia, New Zealand and those in Northern Europe or Western Europe*

YESNO
Current or planned immunosuppression, including human immunodeficiency virus (HIV) infection, organ transplant recipient, treatment with a TNF-alpha antagonist (e.g., infliximab, etanercept, or other), chronic steroids (equivalent of prednisone ≥15 mg/day for ≥1 month) or other immunosuppressive medication*

YESNO
Close contact with someone who has had infectious TB disease since the last TB test/screening*

YESNO
Screening Information

Please indicate the appropriate answer. If "yes," please explain.

Have you recently or currently have any of the below symptoms?*

	NO	YES	Explanation/Comments
1. A bad cough that lasts 3 weeks or longer?
2. Pain in the chest?
3.Coughing up blood or sputum (phlegm from deep inside the lungs)?
4. Unexplained weakness or fatigue?
5. Unexplained weight loss?
6. No appetite?
7. Chills?
8. Fever?
9. Unexplained sweating at night?

Employee Signature*

Clear
Questions?

Contact our Occ Health team at: OccupationalHealth-SGMC_Rehab@adventisthealthcare.com
Should be Empty:

TUBERCULOSIS SCREENING QUESTIONNAIRE