Lending Hands Annual TB Symptom Screening Form
Annual tuberculosis symptom screening for employees of Lending Hands Home Care LLC.
Employee Name
Position/Title
Date of Hire
-
Month
-
Day
Year
Date
Date of Screening
-
Month
-
Day
Year
Date
Have you had a persistent cough lasting longer than three (3) weeks?
Yes
No
Have you coughed up blood?
Yes
No
Have you experienced chest pain?
Yes
No
Have you experienced unexplained weight loss?
Yes
No
Have you experienced night sweats?
Yes
No
Have you had a fever for an extended period?
Yes
No
Have you experienced unusual fatigue?
Yes
No
Have you been in close contact with anyone diagnosed with active TB?
Yes
No
Have you traveled to or lived in an area where TB is common?
Yes
No
Do you have any immunocompromising conditions?
Yes
No
Employee Signature
Date
-
Month
-
Day
Year
Date
Submit
Submit
Should be Empty: