Student Tuberculosis (TB) Management

Please complete.

Today's Date *

First Name *

Last Name *

E-mail Address *

Please check one: *
Resident   Student   Observer   Trainee   Other  

School Name *

School Program *

1. In the past 12 months, have you had temporary or permanent residence (1 month or longer) in any country OTHER THAN the United States, Canada, Australia, New Zealand, or countries in western or northern Europe? *
YES   NO  

If so, where and for how long?

Immunosuppression: This includes HIV infection, organ transplant, treatment with a Tumor Necrosis Factor (TNF) - alpha antagonist (infliximab, etanercept, etc.), chronic steroids (equivalent or more than prednisone 15 mg per day for 1 month), or other immunosuppressive medication.


2. Do you have current or planned immunosuppression? *
YES   NO  

3. Have you had close contact with someone who was diagnosed with infectious Tuberculosis (TB) in the past 12 months? *
YES   NO  

4. Within the last three months, have you had a prolonged, productive cough (3 weeks or longer)? *
YES   NO  

5. Within the last three months, have you been coughing up bloody or discolored sputum? *
YES   NO  

6. Within the last three months, have you had unexplained fever/chills? *
YES   NO  

7. Within the last three months, have you had unexplained chest pain? *
YES   NO  

8. Within the last three months, have you had unexplained night sweats? *
YES   NO  

9. Within the last three months, have you had unexplained fatigue or weakness? *
YES   NO  

10. Within the last three months, have you had unexplained weight loss? *
YES   NO  

11. Within the last three months, have you had a loss of appetite? *
YES   NO  

12. Have you ever received a BCG vaccine? *
YES   NO  

13. Have you ever had a positive TB test? *
YES   NO  

14. If you answered yes to question #13, what type of TB testing did you have? *
TB Skin Test or PPD   QFT or T-Spot (Blood Test)   Unsure   Select if you answered "No" to question #13  

15. If you answered yes to question #13, have you had a chest x-ray within the past 2 years? *
YES   NO   Select if you answered "No" to question #13  

16. If you answered yes to question #13, did you receive treatment after the positive TB test? *
YES   NO   Select if you answered "No" to question #13  

17. If you answered yes to question #13, have you had prolonged/productive cough, bloody or discolored sputum, fever/chills, unexplained chest pain, night sweats, unexplained fatigue/weakness, or unexplained weight loss or loss of appetite in the past 12 months? *
YES   NO   Select if you answered "No" to question #13  

By typing my FULL NAME - I certify that the information on this form is correct and complete to the best of my knowledge. *