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Tuberculosis Risk Assessment
Tuberculosis Risk Assessment
Name
First
DOB
Month
Day
Year
Email
Last 4 of SS#
History of temporary or permanent residence (forτ 1 month) in a country with a high TB rate (i.e., any country other than Australia, Canada, New Zealand, the USA, and those in western or northern Europe)
Yes
No
Please explain
Current or planned immunosuppression, including HIV infection, receipt of an organ transplant, treatment with an TNF-alpha antagonist (e.g., infliximab, etanercept, or other), chronic steroids (equivalent of prednisone τ 15 mg/day for τ 1 month) or other immunosuppressive medication
Yes
No
Please explain
Close contact with someone who has had TB disease
Yes
No
Please explain
Treatment for latent TB infection
Yes
No
Please explain
Prior diagnosis of active TB or latent TB infection or a positive skin test or positive blood test for TB
Yes
No
Please explain
Treatment with medication for TB or for a positive TB test
Yes
No
Please explain
Productive cough for more than 3 weeks
Yes
No
Please explain
Coughing up blood
Yes
No
Please explain
Unexplained Weight Loss
Yes
No
Please explain
Fever, chills, or drenching night sweats for no known reason
Yes
No
Please explain
Persistent shortness of breath
Yes
No
Please explain
Unexplained fatigue for more than 3 weeks
Yes
No
Please explain
Chest pain
Yes
No
Please explain
Employee Signature
Date
MM slash DD slash YYYY
