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TB Screening Form

Annual Tuberculosis Screening Form for Volunteers

Please complete and submit this form.

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?
- Productive cough or persistent cough (longer than two weeks duration)
- Night sweats
- Fever, low grade
- Weight loss
- Loss of appetite
- Fatigue
- Hemoptysis (blood in sputum)
***IF YOU DEVELOP ANY OF THE ABOVE, YOU MUST REPORT IT TO YOUR MANAGER IMMEDIATELY***
Signature*
Date*
Date Format: MM slash DD slash YYYY
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

TB Fact Sheet from the Centers for Disease Control: http://www.cdc.gov/tb/publications/factsheets/general/tb.pdf

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Career Opportunities

UPCOMING EVENTS

20
Jul

New Volunteer Orientation – Lombard – July 20

Saturday, July 20 JourneyCare Administrative Office 1 East 22nd Street, Lombard Our 6-hour Volunteer ... MORE>>

22
Jul

New Volunteer Orientation – Chicago – July 22

Monday, July 22 JourneyCare Administrative Office 549 West Randolph Street, Suite 100, Chicago Our 6-hour ... MORE>>

25
Jul

Senior Forum w/ PLOWS and Rep. Fran Hurley

view full calendar>

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