• Low Risk Tuberculosis (TB) Declaration

    For clinicians of low risk of TB. Please note this form is not suitable for individuals who are at risk of TB as they will require assessment by their local TB or Chest Service.

  • Your Personal Information

  • Format: 0000000000.

  • Part A: Symptoms requiring investigation to exclude active TB disease.

  • Do you currently have any of the following symptoms that are not related to an existing diagnosis or condition that is being managed with a doctor?

  • Cough for more than 2 weeks?*

  • If you have had a cough for more than 2 weeks that is not related to an existing diagnosis or condition that is being managed by a doctor, you will be required to undertake TB screening therefore cannot use this form.

  • Episodes of haemoptysis (coughing blood) in the past month?*

  • If you have had episodes of haemoptysis (coughing blood) in the past month that is not related to an existing diagnosis or condition that is being managed by a doctor, you will be required to undertake TB screening therefore cannot use this form.

  • Unexplained fevers, chills or night sweats in the past month?*

  • If you have had unexplained fevers, chills or night sweats in the past month that is not related to an existing diagnosis or condition that is being managed by a doctor, you will be required to undertake TB screening therefore cannot use this form.

  • Significant* unexpected weight loss over the past 3 months?*loss of more than 5% of body weight*

  • If you have had significant unexpected weight loss over the past 3 months (of more than 5% of body weight) that is not related to an existing diagnosis or condition that is being managed by a doctor, you will be required to undertake TB screening therefore cannot use this form.

  • Part B: Previous TB treatment or TB screening or increased susceptibility

  • Have you ever been treated for active TB disease or latent TB infection (LTBI)?*

  • If you have previously been treated for active TB disease or latent TB infection (LTBI), you are required to provide evidence of a valid negative IGRA or TST result, therefore cannot use this form.

  • Have you ever had a positive TB skin test (TST) or blood test (IGRA orQuantiFERON TB Gold+)?*

  • If you have previously had a positive TB skin test (TST) or blood test (IGRA orQuantiFERON TB Gold+) you are required to provide evidence of a valid negative IGRA or TST result, therefore cannot use this form.

  • Do you have any medical conditions that affect your immune system? e.g. cancer, HIV, auto- immune conditions such as rheumatoid arthritis, renal disease*

  • If you have a medical conditions that affect your immune system e.g. cancer, HIV, auto- immune conditions such as rheumatoid arthritis, renal disease you are required to provide evidence of a valid negative IGRA or TST result, therefore cannot use this form.

  • Are you on any regular medications that suppress your immune system? e.g. TNF alpha inhibitors, high dose prednisone*

  • If you are on any regular medications that suppress your immune system e.g. TNF alpha inhibitors, high dose prednisone you are required to provide evidence of a valid negative IGRA or TST result, therefore cannot use this form.

  • Part C: Possible TB exposure risk history

    The following questions explore possible previous exposure to TB
  • Were you born in Australia?*
  • Is your country of birth on the list of high-TB-incidence countries? https://www.health.nsw.gov.au/Infectious/tuberculosis/Pages/high-incidence-countries.aspx*

  • I was born in   *   and moved to Australia in *   

  • As you were born in a country of high-TB-incidence you are required to undertake TB screening. You will be required to provide evidence of a negative TB skin test (TST) or blood test (IGRA or QuantiFERON TB Gold+), therefore cannot use this form.

  • Have you had direct contact with a person with infectious pulmonary TB without adequate personal protective equipment and did not complete contact screening?*

  • As you have had direct contact with a person with infectious pulmonary TB without adequate personal protective equipment and did not complete contact screening, you will be required to undertake TB screening therefore cannot use this form.

  • Have you ever visited or lived in any country/ies with a high TB incidence in your life(first assessment) or since your last TB Assessment? https://www.health.nsw.gov.au/Infectious/tuberculosis/Pages/high-incidence-countries.aspx*

  • As you have visited or lived in a country/ies with a high TB incidence, either in your life (first assessment) or since your last TB Assessment, you will be required to undertake TB screening, therefore cannot use this form.

  • Should be Empty: