Baseline Individual TB Risk Assessment
McCurtain Memorial Hospital Infection Control
Today's Date:
-
Month
-
Day
Year
Date
Employee's Full Name
*
First Name
Last Name
Email
*
example@example.com
Have you been a temporary or permanent resident for more than (1) one month in a country with a high TB rate?
*
Yes
No
Current or planned immunosuppression?
*
Yes
No
Close contact with someone who has had infectious TB disease since the last TB test?
*
Yes
No
Please Sign
*
Preview PDF
Submit
Should be Empty: