TB Screening Questionnaire free printable template

TB SCREENING QUESTIONNAIRE // First name Last name Middle name Date of birth Address Home phone City Cell or work phone State Zip Today s date CIRCLE ANY OF THE BELOW SYMPTOMS YOU HAVE TODAY Cough Coughing up blood Fever Weight loss Tiredness Night sweats PLEASE ANSWER THESE QUESTIONS Why do you need a TB test today Have you ever had a positive TB skin test or TB blood test Yes No Don t Know Have you had a severe reaction to a TB skin test Have you ever taken medication for tuberculosis Have...

How to fill out printable tb test form for employment

How to fill out TB Screening Questionnaire

1. Read the instructions carefully provided at the top of the TB Screening Questionnaire.
2. Begin with personal information, filling out your full name, date of birth, and contact details.
3. Answer questions regarding your medical history honestly, including any previous TB infections or treatments.
4. Indicate any symptoms you may be experiencing, such as a persistent cough or unexplained weight loss.
5. Provide information about any recent travel to areas with high TB rates.
6. If applicable, note any close contact you may have had with someone who has active TB.
7. Review your answers for accuracy before finalizing the form.
8. Submit the questionnaire as instructed, whether online or in person.

Who needs TB Screening Questionnaire?

1. Individuals who have symptoms of TB infection.
2. People who have been in close contact with someone diagnosed with active TB.
3. Individuals who are getting tested for TB as part of pre-employment or school requirements.
4. People who have traveled to or lived in areas with high rates of TB.
5. Healthcare workers and others in high-risk occupations.

People Also Ask about tb questionnaire form pdf

What are the 4 TB screening questions?

Please answer the following questions: Have you ever had a positive TB skin test? Have you ever had close contact with anyone who was sick with TB? Have you ever been vaccinated with BCG? * The significance of the travel exposure should be discussed with a health care provider and evaluated.

What is TB screening questions?

Have you ever had a positive TB skin test? Have you ever had close contact with anyone who was sick with TB? Have you ever been vaccinated with BCG?

When should TB screening questionnaire be given?

Post-Exposure Screening and Testing All health care personnel with a known exposure to TB disease should receive a TB symptom screen and timely testing, if indicated. Health care personnel with a previous negative TB test result should be tested immediately and re-tested 8 to 10 weeks after the last known exposure.

How often do you need Quantiferon gold test?

The CDC guidelines on the use of QFT recommend that recent contacts who test QFT negative prior to 8 weeks after the end of exposure, be retested 8 to 10 weeks later—similar to the recommendations for the TST.

What is a TB screening questionnaire?

What is a tuberculosis (TB) screening? A tuberculosis screening test checks to see if you have the bacteria (germs) that cause tuberculosis (TB) in your body. TB is a bacterial infection that mainly attacks the lungs. But it can also affect other parts of the body, including the brain, spine, and kidneys.

What are the steps of TB screening?

A TB skin test requires two visits with a health care provider. On the first visit the test is placed; on the second visit the health care provider reads the test. The TB skin test is performed by injecting a small amount of fluid (called tuberculin) into the skin on the lower part of the arm.

Should Quantiferon gold test be done yearly?

A repeat TB test (e.g., TB blood test or a TB skin test) is not required. Annual TB testing of health care personnel is not recommended unless there is a known exposure or ongoing transmission at a healthcare facility.

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What is TB Screening Questionnaire?

The TB Screening Questionnaire is a tool used to determine if an individual is at risk for tuberculosis (TB) and whether they should receive further testing.

Who is required to file TB Screening Questionnaire?

Individuals who are applying for certain jobs, immigration, or healthcare positions, as well as those who have been in contact with people diagnosed with TB, are typically required to file a TB Screening Questionnaire.

How to fill out TB Screening Questionnaire?

To fill out the TB Screening Questionnaire, provide accurate and complete responses to the questions presented, ensuring to disclose any relevant medical history and potential exposure to TB.

What is the purpose of TB Screening Questionnaire?

The purpose of the TB Screening Questionnaire is to identify individuals who may have active or latent TB infection, allowing for appropriate evaluation and potential treatment to prevent the spread of TB.

What information must be reported on TB Screening Questionnaire?

The TB Screening Questionnaire typically requires reporting of personal health history, exposure to TB, symptoms such as cough or fever, and previous TB test results.