TB Screening Form – JourneyCare Home Health & Hospice

Name *

First

Last

Have you ever had tuberculosis? *

If yes, please explain including date of positive test, circumstances and treatment involved.

Have you ever had a TB skin test (TST)? *

Yes
No

Have you ever had a POSITIVE TB skin test? *

Yes
No

If yes, please state when and describe action taken or treatment received.

Have you ever had a BCG vaccine? (given in certain countries to prevent TB.) *

Yes
No

Do you currently have any of the following symptoms?

***IF YOU DEVELOP ANY OF THE ABOVE, YOU MUST REPORT IT TO YOUR MANAGER IMMEDIATELY***

Signature *

Date / Time *

Date

Time

I have read the information regarding T.B. skin testing and have had an opportunity to ask questions. I have supplied my current medical information. *

Agree