TB SCREENING & SYMPTOMS EVALUATION FORM
To be completed by employee:
Print Name
Have you ever had a positive TB skin test or history of TB infection? If the answer is YES, please answer the following:
YES
NO
Have you ever had the BCG vaccine?
YES
NO
Do you have prolonged or recurrent fever?
YES
NO
Have you recently lost weight?
YES
NO
Do you have a chronic cough?
YES
NO
Do you cough up blood?
YES
NO
Do you have sweating at night?
YES
NO
Do you have any of the following risk factors which may substantially? Increase the risk of tuberculosis?
YES
NO
a. Silicosis (Lung Disease)
b. Gastrectomy
c. Intestinal Bypass
d. Weight 10% or more below ideal body weight?
e. Chronic Renal Disease
f. Diabetes Mellitus
g. Prolonged high-dose corticosteroid therapy or other Immunosuppressive therapy
h. Hematologic Disorder i.e. leukemia or lymphoma
i. Exposure to HIV or AIDS
j. Other malignancies
Employee Signature
Date
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Month
-
Day
Year
Date
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Health Care Personnel (HCP) Baseline Individual TB Risk Assessment
HCP should be considered at increased risk for TB if any of the following statements are marked "Yes":
Temporary or permanent residence of ≥1 month in a country with a high TB rate
YES
NO
Current or planned immunosuppression, including human immunodeficiency virus (HIV) infection, organ transplant recipient, treatment with a TNF-alpha antagonist (e.g., infliximab, etanercept, or other), chronic steroids (equivalent of prednisone ≥15 mg/day for ≥1 month) or other immunosuppressive medication
YES
NO
Close contact with someone who has had infectious TB disease since the last TB test
YES
NO
Abbreviations: HCP, health-care personnel; TB, tuberculosis; TNF, tumor necrosis factor. Individual risk assessment information can be useful in interpreting TB test results (see Lewinsohn DM, Leonard MK, LoBue PA, et al. Official American Thoracic Society/Infectious Diseases Society of America/Centers for Disease Control and Prevention Clinical Practice Guidelines: Diagnosis of tuberculosis in adults and children. Clin Infec Dis 2017;64;111-5). Adapted from: Risk assessment form developed by the California Department of Health, Tuberculosis Control Branch. Sosa LE, Njie GJ, Lobato MN, et al. Tuberculosis Screening, Testing, and Treatment of U.S. Health Care Personnel: Recommendations from the National Tuberculosis Controllers Association and CDC, 2019. MMWR Morb Mortal Wkly Rep 2019,68:439-43. https://www.cdc.gov/mmwr/volumes/68/wr/mm6819a3.htm?s_cid=mm6819a3_w
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