Swing Education Tuberculosis (TB) Screening

  • Swing Education Tuberculosis (TB) Screening

    GENERAL Risk Assessment Questionnaire

  • The purpose of this tool is to identify adults with infectious tuberculosis (TB) to prevent them from spreading disease.

    Do not repeat testing unless there are new risk factors since the last negative test. For individuals with signs or symptoms of TB disease or abnormal chest x-ray consistent with TB disease, evaluate for active TB disease with a chest x-ray, symptom screen, and if indicated, sputum AFB smears, cultures and nucleic acid amplification testing. A negative tuberculin skin test (TST) or interferon gamma release assay (IGRA) does not rule out active TB disease.
  • Date of Birth*
     - -
  • Format: (000) 000-0000.
  • DO YOU HAVE A HISTORY OF TUBERCULOSIS OR INFECTION?*
    • Assess Risk Factors for Tuberculosis using boxes below 
    • Do you currently have one or more sign(s) or symptom(s) of TB disease (prolonged cough, coughing up blood, fever, night sweats, weight loss, or excessive fatigue)?*
    • Have you spent extended periods of time (born in, traveled to, or maintained residence) in a country with elevated rates of TB infection for at least one month (Includes countries other than the United States, Canada, Australia, New Zealand, or Western and Northern European countries)?*
    • Have you had close contact to someone with infectious TB disease during your lifetime?*

    • Treat for latent tuberculosis infection (LTBI) if TB Test Result is Positive and active TB disease is ruled out.

      THIS SCREENING TOOL IS FOR REVIEW BY AUTHORIZED MEDICAL PERSONNEL AND UNAUTHORIZED USE IS STRICTLY PROHIBITED. The law requires that a healthcare provider to administer this questionnaire. A healthcare provider, as defined for this purpose, is any organization, facility, institution or person licensed, certified or otherwise authorized or permitted by state law to deliver or furnish health services. A Certificate of Completion will be completed after screening is completed.
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