Tb annual screening - University of Cincinnati

University Health Services University of Cincinnati 1st Floor Holmes P.O. Box 670460 Cincinnati, OH 45267-0460 Phone: 584-4457 Fax: 584-2222

Annual TB Screening Questionnaire

annual preplacement 1 step

2 step

post exposure

Today's date: ______/________/_________

Name:____________________________________________________ Age: __________ Please print

Birth date: ________/_________/_________

Male Female SS #__________/________/____________ OR M #_________________________________ Race ______________

Birthplace: ____________________________________ Occupation _______________________________________________

1 Do you have a history of positive TB skin Test, or history of having TB?

Yes No

2 Do you now have any condition requiring prolonged steroid or immunosuppressive therapy?

Yes No

3 Do you have an immunosuppressive illness at the present time?

Yes No

4 Have you had any of the following in the past year?

Yes No

Section A

a. Recent, close contact with any person having active tuberculosis?

Yes No

b. Unexplained productive cough?

Yes No

c. Coughing up blood?

Yes No

d. Unexplained weight loss or increased fatigue? e. Unexplained fever or night sweats?

Yes No

Yes No

5 Have you ever had BCG vaccine? . (Vaccine given primarily in foreign countries where there is a high incidence of tuberculosis)

Yes No

STOP HERE If you have +PPD documentation on file with University Health Services you are not required to complete section B.

I Understand that my PPD skin test must be read and documented by a physician 48 ? 72 hours after the injection. This form must be returned to University Health Services.

Signature:____________________________________________________

SITE:

DATE ADMINISTERED: DATE READ: RESULT:

Administered by: Read by: MM INDURATION:

Section B

If any redness or induration appears, the skin test must be read and measured by the University Health Services medical staff. Failure to have the site appropriately read and documented will render the test invalid.

SITE:

DATE ADMINISTERED:

Administered by:

DATE READ:

Read by:

RESULT:

MM INDURATION:

8/2012

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