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Tuberculosis (TB) Screening Update Form

Name(Required)
Were you born in, or during the past 5 years, have you lived in any of the countries listed below?(Required)
Have you had frequent or prolonged visits to one or more of the countries listed below?(Required)
  • Afghanistan
  • Albania
  • Algeria
  • Andorra
  • Angola
  • Antigua and Barbuda
  • Argentina
  • Armenia
  • Australia
  • Austria
  • Azerbaijan
  • Bahamas
  • Bahrain
  • Bangladesh
  • Barbados
  • Belarus
  • Belgium
  • Belize
  • Benin
  • Bhutan
  • Bolivia
  • Bosnia and Herzegovina
  • Botswana
  • Brazil
  • Brunei
  • Bulgaria
  • Burkina Faso
  • Burundi
  • Cabo Verde
  • Cambodia
  • Cameroon
  • Canada
  • Central African Republic
  • Chad
  • Chile
  • China
  • Colombia
  • Comoros
  • Congo (Brazzaville)
  • Congo (Kinshasa)
  • Costa Rica
  • Croatia
  • Cuba
  • Cyprus
  • Czech Republic
  • Denmark
  • Djibouti
  • Dominica
  • Dominican Republic
  • Ecuador
  • Egypt
  • El Salvador
  • Equatorial Guinea
  • Eritrea
  • Estonia
  • Eswatini
  • Ethiopia
  • Fiji
  • Finland
  • France
  • Gabon
  • Gambia
  • Georgia
  • Germany
  • Ghana
  • Greece
  • Grenada
  • Guatemala
  • Guinea
  • Guinea-Bissau
  • Guyana
  • Haiti
  • Honduras
  • Hungary
  • Iceland
  • India
  • Indonesia
  • Iran
  • Iraq
  • Ireland
  • Israel
  • Italy
  • Ivory Coast
  • Jamaica
  • Japan
  • Jordan
  • Kazakhstan
  • Kenya
  • Kiribati
  • Korea, North
  • Korea, South
  • Kosovo
  • Kuwait
  • Kyrgyzstan
  • Laos
  • Latvia
  • Lebanon
  • Lesotho
  • Liberia
  • Libya
  • Liechtenstein
  • Lithuania
  • Luxembourg
  • Madagascar
  • Malawi
  • Malaysia
  • Maldives
  • Mali
  • Malta
  • Marshall Islands
  • Mauritania
  • Mauritius
  • Mexico
  • Micronesia
  • Moldova
  • Monaco
  • Mongolia
  • Montenegro
  • Morocco
  • Mozambique
  • Myanmar
  • Namibia
  • Nauru
  • Nepal
  • Netherlands
  • New Zealand
  • Nicaragua
  • Niger
  • Nigeria
  • North Macedonia
  • Norway
  • Oman
  • Pakistan
  • Palau
  • Palestine
  • Panama
  • Papua New Guinea
  • Paraguay
  • Peru
  • Philippines
  • Poland
  • Portugal
  • Qatar
  • Romania
  • Russia
  • Rwanda
  • Saint Kitts and Nevis
  • Saint Lucia
  • Saint Vincent and the Grenadines
  • Samoa
  • San Marino
  • Sao Tome and Principe
  • Saudi Arabia
  • Senegal
  • Serbia
  • Seychelles
  • Sierra Leone
  • Singapore
  • Slovakia
  • Slovenia
  • Solomon Islands
  • Somalia
  • South Africa
  • South Sudan
  • Spain
  • Sri Lanka
  • Sudan
  • Suriname
  • Sweden
  • Switzerland
  • Syria
  • Taiwan
  • Tajikistan
  • Tanzania
  • Thailand
  • Timor-Leste
  • Togo
  • Tonga
  • Trinidad and Tobago
  • Tunisia
  • Turkey
  • Turkmenistan
  • Tuvalu
  • Uganda
  • Ukraine
  • United Arab Emirates
  • United Kingdom
  • United States
  • Uruguay
  • Uzbekistan
  • Vanuatu
  • Vatican City
  • Venezuela
  • Vietnam
  • Yemen
  • Zambia
  • Zimbabwe
Have you been in close contact with a person known or suspected to have active Tuberculosis disease (TB)?(Required)
Do you work in or live in a high-risk congregate setting (e.g., a correctional facility, long-term care facility, homeless shelter, etc.)?(Required)
Have you worked as a health care worker serving clients who are at increased risk for active Tuberculosis?(Required)
Are you or have you abused drugs or alcohol or do you have a medical condition that weakens your immune system (e.g., HIV).?(Required)
Are you currently or have you recently experienced symptoms of Tuberculosis (e.g., fever, night sweats, cough and weight loss)?(Required)
I certify that I have answered these questions truthfully to the best of my ability.(Required)

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