TB Screening Form

First Name of Person Getting TB test

First Name

Last Name of Person Getting TB test

Last Name

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Date of Birth

Date

Age

If person getting the TB test is under the age of 18, this form needs to be filled out and signed by a parent/guardian

Address

Street Address

Street Address Line 2

CityState

Zip Code

County of Residence

Gender

Ethnicity

Race

Preferred Language

Email for confirmation notification of form

example@example.com

Reason for Test

This test will need to be read in 48-72 hours. Failure to have it read in that time frame by a Nurse, will result in needing another test.

1. Have you ever had a POSITIVE Tuberculin skin test?

If Yes, please explain 1

2. Have you had known exposure to TB?

If Yes, please explain 2

3. Have you ever been diagnosed with OR treated for TB Disease? When?

If Yes, please explain 3

4. Have you ever had an abnormal CXR (chest X-ray) suggestive of TB?

If Yes, please explain 4

5. Have you ever had BCG vaccination?

If Yes, please explain 5

6. Are you a resident, employee, or volunteer in a high-riskcongregate setting (correctional facility, nursing home, homeless shelter, hospitals, other healthcare facilities)?

If Yes, please explain 6

7. .Do you have a cough lasting 3 weeks or longer, chest pain, weakness, fatigue, weight loss, chills, fevers, and/or night sweats?

If Yes, please explain 7

8. Are you coughing up blood or phlegm?

If Yes, please explain 8

9. Have you had an MMR or Varicella Vaccination in the last 4 weeks?

If Yes, please explain 9

10. Have you traveled or lived outside the U.S. in the past 2years? (where?)

If Yes, please explain 10

Person Signing Consent

Name of Parent/Guardian/Responsible Party

First NameLast Name

Parent Guardian Date of Birth

MonthDayYear

Withdrawal of consent

You may withdraw your consent at any time by calling Pike County Health Department at 573-324-2111. Staff will send a confirmation email/mailed paper copy for verification. Withdrawal will not affect services already rendered, but may impact ongoing service delivery.

Signature

Date

Tuberculosis (TB) Screening Form