Tuberculosis (TB) Screening Update Form

Name(Required)
Were you born in, or have you lived or worked in any of the following within the last five years: Asia, Africa, South America, Central America, or Eastern Europe?(Required)
Have you had frequent or prolonged visits to Asia, Africa, South America, Central America, or Eastern Europe within the last two months?(Required)
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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