DEPARTMENT OF HEALTH SERVICES
Division of Quality Assurance
F-01679 (12/2015)
STATE OF WISCONSIN
Wis. Admin. Code § DHS 105.17(1r)(a-b)
COMMUNICABLE DISEASE / TUBERCULOSIS SCREENING QUESTIONNAIRE
The Department requires that health care agencies or providers screen all health care staff WITHIN 90 DAYS BEFORE DIRECT CONTACT AND PERIODICALLY, to ensure that staff is free of any communicable diseases before coming into contact with clients. This form is intended to provide guidance for providers. Use of this form is optional.
Name - Employee Completing Form
COMMUNICABLE DISEASE SCREENING
Are you experiencing any of the following symptoms?
1. Sore throat
Yes
No
2. Rash / vesicles on skin
Yes
No
3. Cold sore
Yes
No
4. Fever and rash
Yes
No
5. Fever and respiratory symptoms - cough, runny nose
Yes
No
6. Drainage from eyes, ears
Yes
No
7. Skin lesion, cyst, boil
Yes
No
8. Nausea, vomiting
Yes
No
9. Diarrhea
Yes
No
10. Cough lasting more than three weeks
Yes
No
11. Swollen lymph nodes
Yes
No
12. Non healing wound
Yes
No
13. Returned from travel in another country within the last month
Yes
No
Have you ever been told by a physician or other health care provider that you have any of the following conditions?
14. Hepatitis A, B, or C
Yes
No
15. Tuberculosis
Yes
No
16. HIV / AIDS
Yes
No
TUBERCULOSIS (TB) SCREENING
Are you experiencing any of the following symptoms?
17. Persistent coughing
Yes
No
18. Coughing up bloody sputum or blood
Yes
No
19. Night sweats
Yes
No
20. Unexplained fatigue
Yes
No
21. Fever recurring
Yes
No
22. Unexplained weight loss
Yes
No
23. Positive for TB - either skin test or blood test
Yes
No
24. Have you ever been told by a health care provider that you have had active TB?
Yes
No
25. Have you ever cared for or lived with anyone diagnosed with active TB?
Yes
No
26. Have you worked or volunteered in a setting where TB may be more common, e.g., homeless shelter, nursing home, group home, prison?
Yes
No
Depending on the responses to the above questions, the registered nurse (RN) reviewing this document may refer you for a follow-up appointment with your physician, nurse practitioner (NP), or physician's assistant (PA). At this appointment you will receive written documentation that you pose no risk for exposing others to communicable diseases.
I acknowledge that the above information is true and correct to the best of my knowledge.
SIGNATURE - Employee Completing Form
Date Signed (MM/dd/yyyy)
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Month
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Day
Year
Date
Submit
Submit
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