TB Screening Form Annual Tuberculosis Screening Form for Volunteers Please complete and submit this form. Name* First Last Have you ever had tuberculosis?*YesNoIf yes, please explain including date of positive test, circumstances and treatment involved.Have you ever had a TB skin test (TST)?*YesNoHave you ever had a POSITIVE TB skin test?*YesNoIf 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.)*YesNoDo 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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