Tuberculosis (TB) Symptom Assessment
Employee Name
*
First Name
Last Name
Division-Location:
*
Park West ICF
Johnstown ICF
Supported Living
Day Services (CAC, NMT, ODAS, UCO)
Corporate/Admin
Date completed:
*
-
Month
-
Day
Year
Date
In the past twelve (12) months, have you experienced any of the following symptoms relating to TB symptoms?
*
YES
NO
Persistent cough for more than 3 weeks in duration
Cough producing bloody or brown sputum
Fever or chills
Night Sweats
Prolonged or excessive fatigue
Loss of appetite
Unintentional weight loss (greater than 10 lbs)
IF Yes, list explanation below:
INITIAL SCREENING ONLY: (only choose one)
*
I have a past history of positive TB skin test
I have completed course of preventative TB medicine
I am currently taking preventative TB medicine
I have never taken preventative TB medicine
If history of positive TB, or preventative medicine, list details of date and information below:
Upload copy of chest xray results here:
Browse Files
Cancel
of
Employee Email
*
example@example.com
Employee Signature:
*
Submit
Should be Empty: