TB SYMPTOM SCREENING FORM

TB SYMPTOM SCREENING FORM
Employee Name*

First NameLast Name
Please complete the symptom screen below. The questions are reflective of symptoms that may be experienced when infected with tuberculosis. Check the appropriate response for each question, sign below and submit for your records. This screening form is to be completed annually.

Have you experienced any of the following?
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
It is important to observe standard precautions at all times when caring for patients. Frequent hand washing, covering mouth and nose when coughing and sneezing are important safe guards.
Employee Signature*
Date*

MonthDayYear
Date
Should be Empty: