Communicable Disease / Tuberculosis Screening ...



DEPARTMENT OF HEALTH SERVICESDivision of Quality AssuranceF-01679 (12/2015)STATE OF WISCONSINWis. Admin. Code § DHS 105.17(1r)(a-b)COMMUNICABLE DISEASE / TUBERCULOSIS SCREENING QUESTIONNAIREThe Department requires that health care agencies or providers screen all health care staff WITHIN 90 DAYS BEFORE DIRECT CONTACT AND PERIODICALLY, to ensure that staff is free of any communicable diseases before coming into contact with clients. This form is intended to provide guidance for providers. Use of this form is optional.Name – Employee Completing Form FORMTEXT ?????COMMUNICABLE DISEASE SCREENINGAre you experiencing any of the following symptoms? FORMCHECKBOX Yes FORMCHECKBOX NoSore throat FORMCHECKBOX Yes FORMCHECKBOX NoRash / vesicles on skin FORMCHECKBOX Yes FORMCHECKBOX NoCold sore FORMCHECKBOX Yes FORMCHECKBOX NoFever and rash FORMCHECKBOX Yes FORMCHECKBOX NoFever and respiratory symptoms – cough, runny nose FORMCHECKBOX Yes FORMCHECKBOX NoDrainage from eyes, ears FORMCHECKBOX Yes FORMCHECKBOX NoSkin lesion, cyst, boil FORMCHECKBOX Yes FORMCHECKBOX NoNausea, vomiting FORMCHECKBOX Yes FORMCHECKBOX NoDiarrhea FORMCHECKBOX Yes FORMCHECKBOX NoCough lasting more than three weeks FORMCHECKBOX Yes FORMCHECKBOX NoSwollen lymph nodes FORMCHECKBOX Yes FORMCHECKBOX NoNon healing wound FORMCHECKBOX Yes FORMCHECKBOX NoReturned from travel in another country within the last monthHave you ever been told by a physician or other health care provider that you have any of the following conditions? FORMCHECKBOX Yes FORMCHECKBOX NoHepatitis A, B, or C FORMCHECKBOX Yes FORMCHECKBOX NoTuberculosis FORMCHECKBOX Yes FORMCHECKBOX NoHIV / AIDSTUBERCULOSIS (TB) SCREENINGAre you experiencing any of the following symptoms? FORMCHECKBOX Yes FORMCHECKBOX NoPersistent coughing FORMCHECKBOX Yes FORMCHECKBOX NoCoughing up bloody sputum or blood FORMCHECKBOX Yes FORMCHECKBOX NoNight sweats FORMCHECKBOX Yes FORMCHECKBOX NoUnexplained fatigue FORMCHECKBOX Yes FORMCHECKBOX NoFever recurring FORMCHECKBOX Yes FORMCHECKBOX NoUnexplained weight loss FORMCHECKBOX Yes FORMCHECKBOX NoPositive for TB – either skin test or blood test FORMCHECKBOX Yes FORMCHECKBOX NoHave you ever been told by a health care provider that you have had active TB? FORMCHECKBOX Yes FORMCHECKBOX NoHave you ever cared for or lived with anyone diagnosed with active TB? FORMCHECKBOX Yes FORMCHECKBOX NoHave you worked or volunteered in a setting where TB may be more common, e.g., homeless shelter, nursing home, group home, prison?Depending on the responses to the above questions, the registered nurse (RN) reviewing this document may refer you for a follow-up appointment with your physician, nurse practitioner (NP), or physician’s assistant (PA). At this appointment you will receive written documentation that you pose no risk for exposing others to communicable diseases.I acknowledge that the above information is true and correct to the best of my knowledge.SIGNATURE – Employee Completing FormDate Signed (MM/dd/yyyy) FORMTEXT ?????OFFICE USE ONLY FORMCHECKBOX Yes FORMCHECKBOX NoI have conducted a screening and have reviewed the information on this form. The employee appears to be clinically free from communicable disease and TB. FORMCHECKBOX Yes FORMCHECKBOX NoRN referral to physician, NP, or PASIGNATURE – RN ScreenerName – RN Screener (print) FORMTEXT ?????Date Signed (MM/dd/yyyy) FORMTEXT ????? ................
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