• TB Risk Assessment Survey

    TB Document G: State of Hawaii TB Risk Assessment for Adults and Children

  • Hawaii State Department of Health

    Tuberculosis Control Program

  • 1. Check for TB symptoms

    • If there are significant TB symptoms, then further testing (including a chest x-ray) is required for TB clearance.
    • If significant symptoms are absent, proceed to TB Risk Factor questions.
  • Does this person have significant TB symptoms? Significant symptoms include cough for 3 weeks or more, plus at least one of the following: Coughing, up blood, Fever, Night sweats, Unexplained weight loss, Unusual weakness, Fatigue*
  • If yes, select any/all symptoms:

  • 2. Check for TB Risk Factors

    • If any "Yes" box below is checked, then TB testing is required for TB clearance
    • If all boxes below are checked "No", then TB clearance can be issued without testing
  • Was this person born in a country with an elevated TB rate? Includes countries other than the United States, Australia, New Zealand, or Western and North European countries.*
  • Has this person traveled to (or lived in) a country with an elevated TB rate for four weeks or longer?*
  • At any time has this person been in contact with someone with infectious TB disease? (Do not check "Yes" if exposed only to someone with latent TB)*
  • Does the individual have a health problem that affects the immune system, or is medical treatment planned that may affect the immune system? (Includes HIV/AIDS, organ transplant recipient, treatment with TNF-alpha antagonist, or steroid medication for a month or longer)*
  • For persons under age 16 only: Is someone in the child's household from a country with an elevated TB rate?*
  • Provider Name*
  • Assesment Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Name and Relationship of Person Providing Information (if not the above-named person)

  • Should be Empty: