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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*
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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