PDN Sunbridge TB

TB Clearance Requirement

Sunbridge requires that all staff maintain an active tuberculosis (TB) clearance as part of state health and safety regulations.
You must provide documentation of ONE of the following:

- A TB skin test (Mantoux test) completed within the last 12 months, OR
- A chest X-ray report if you have a history of a positive TB skin test.
This clearance must be up to date and on file before you may begin or continue working with Sunbridge.
Please upload a copy of one of the above

Cancelof
Tuberculosis Risk Assessment Form

Please complete the attached Tuberculosis (TB) Risk Assessment. This form is a state-required document and must be filled out in full. Your responses help determine if any additional testing or evaluation is necessary.
Have you ever had TB Disease*

YesNo
Unplanned Weight Loss*

YesNo
Coughed up blood*

YesNo
Night Sweats*

YesNo
Shortness of Breath*

YesNo
Fatigue*

YesNo
Loss of Appetite*

YesNo
Chest Pain*

YesNo
Hoarseness*

YesNo
Close contact with someone who has had infectious TB disease since the last TB test.*

YesNo
Temporary or permanent residence of one month or less in a country with a high TB rate. (Any country other than the U.S., Canada, Australia, New Zealand, and those in Northern Europe or Western Europe.*

YesNo
Current or planned immunosuppression, Including HIV, organ transplant, treatment with a TNF-alpha antagonist, chronic steroids (equivalent of prednisone less than 15mg/day for 1 month or less) or other immunosuppressive medication*

YesNo
Fever more than 2 weeks duration*

YesNo
Productive Cough*

YesNo
If yes to Productive Cough, please state color
If yes to Productive Cough, please state consistency
If yes to Productive Cough, is there blood in Sputum

YesNo
Date

MonthDayYear
Date
Signature
Training Document Acknowledgement
Please review
I have read and reviewed the following TB training document
Signature
Date

MonthDayYear
Date
Name*

First NameLast Name
Should be Empty:

Training Document Acknowledgement