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
Date of Birth

MonthDayYear
Date
Employee ID
Preferred Phone Number
Format: (000) 000-0000.
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
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
Close contact with someone who has had infectious TB disease since the last TB test/screening
Screening Information

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

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

Rows	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
Questions?

Contact our Occ Health team at: OccupationalHealth-SGMC_Rehab@adventisthealthcare.com
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TUBERCULOSIS SCREENING QUESTIONNAIRE