TB Screening 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

Annual Tuberculosis Screening Form for Volunteers

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