Tuberculosis (TB) Screening & Risk Assessment
Today's Date
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Month
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Day
Year
Date
Employee's Legal Name
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First Name
Last Name
CPR Email Address
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example@example.com
Have you ever had TB or a positive TB skin test?
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YES
NO
Have you EVER spent more than 30 days in a country with an elevated TB rate? This includes all countries except those in Western Europe, Northern Europe, Canada, Australia, and New Zealand.
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YES - I have been in a foreign country for >30 days (not including those listed above)
NO - I have not been in any country for >30 days except the ones listed above
Have you had close contact with anyone who had active TB since your last TB test?
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YES
NO
Do you currently have any of the following symptoms:
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Unexplained fever for more than 3 weeks
Cough for more than 3 weeks with sputum production
Bloody sputum
Unintended weight loss >10 pounds
Drenching night sweats
Unexplained fatigue for more than 3 weeks
NO - NONE OF THE ABOVE
Have you ever been diagnosed with active TB disease?
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YES
NO
Have you ever been diagnosed with latent TB infection or had a positive skin test or a positive blood test for TB?
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YES - one or more of these is true for me
NO - none of these are true for me
Have you been treated with medication for TB or for a positive TB test (eg, taken "INH")?
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YES
NO
What year, with which medication, for how long, and did you complete the treatment course?
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Do you have a weakened immune system for any reason including organ transplant, recent chemotherapy, poorly controlled diabetes, HIV infection, cancer, or treatment with steroids for more than 1 month, immune-suppressing medications such as a TNF-alpha antagonist or another immune-modulator? (If you are not sure, ask your Occupational Health provider)
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YES - one or more of these are true for me
NO - none of these are true for me
Submit
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