Tuberculosis Symptom Screening Questionnaire ml
Tuberculosis Symptom Screening Questionnaire to be used
During PPD (Purified Protein Derivative) Shortage
The Centers for Disease Control and Prevention (CDC) has declared a shortage of PPD solution used for administering the TB Skin Test (TST). This form is to be used for persons who are required to have TB screening for employment, post-secondary educational institution admission, long term residential care admission, correctional facility intake, or fulfillment of other statute or regulation. Part A should be completed by the person for whom the TB Skin Test is required. A healthcare professional must evaluate the answers and assign a recommendation from Part B.
? If testing is deferred, the healthcare provider must check with their PPD solution supplier regularly to determine if PPD is available, and recall all patients with deferred TSTs as soon as is practical.
? Prior to using the form, all responsible facilities (skilled nursing facilities, home health care etc.) should verify that the suggested process is acceptable to their regulatory authority.
PART A 1. Have you experienced any of the following symptoms in the past year? a.) A productive cough for more than 3 weeks? b.) Hemoptysis (coughing up blood)? c.) Unexplained weight loss? d.) Fever, Chills, or night sweats for no known reason? e.) Persistent shortness of breath? f.) Unexplained fatigue? g.) Chest Pain?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
2. Have you had contact with anyone with active tuberculosis disease in the past year?
Yes
No
3) Do you have a medical condition, or are you taking medications, which suppress
your immune system?
Yes
No
3. Why are you required to have a TB Skin Test? ______________________________________________________________________ Please provide details to any question answered "Yes".
I declare that my answers and statements are correctly recorded, complete, and true to the best of my knowledge.
_______________________________________ ________________________________________ _______
Signature of person required to be tested
Printed Name
Date
PART B Upon review of the responses to the questionnaire and discussion with the person for whom the tuberculosis evaluation is required, I recommend as follows:
_______There is no indication this person has active tuberculosis at this time. Their TB Skin Test should be deferred
until the National PPD shortage has ended. Interferon Gamma Release Assay (IGRA) TB Blood Test may be
considered as an alternative, if practicable. (client is insured, or can afford out of pocket ).
_______ Further evaluation, including a TB Skin Test, Interferon Gamma Release Assay or other medical evaluation
is indicated, and should be completed prior to work placement or admission to a facility.
________________________________________ __________________________________ ___________
Healthcare Professional Signature
Printed Name
Date
____________________________________________ ________________________
Agency/Practice Name
Contact Phone
................
................
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