Assist Medical Staffing

TB Questionnaire

By completing this Questionnaire, you are attesting that you have had a positive/sensitive TB skin test or that your physician/NP/PA has deemed you ineligible for the TB skin test due to medical reasons or that completion of the form is a state or client requirement. Therefore upon hire and annually thereafter you are required to complete this Questionnaire. For positive/sensitive TB skin tests: Please submit a current, clear chest x-ray upon hire.

TB INFECTION HISTORY

Have you ever been treated for latent TB infection? Yes No

Have you ever been treated for active TB disease? Yes No

Please read and put a checkmark in the correct Yes/No space if you are experiencing any of the following symptoms or if any of the following apply to you:

Symptoms

1. Unplanned loss of weight (>10% of body weight) Yes No

2. Night sweats Yes No

3. Fever lasting several weeks Yes No

4. Frequent coughing in the absence of a cold or flu Yes No

5. Production of sputum Yes No

6. Coughing blood-streaked sputum Yes No

7. Unusual tiredness or weakness lasting weeks Yes No

8. Shortness of breath Yes No

9. Pain in chest when taking a breath Yes No

10. Have you been recently diagnosed with diabetes, silicosis, HIV disease, renal disease or liver disease? Yes No

11. Have you been recently exposed to a family member or others with active TB? Yes No

If you checked YES to any of the above symptom questions, is a physician currently treating you? Yes No

IF YOU DEVELOP ANY OF THE SYMPTOMS LISTED ABOVE, PLEASE CONTACT YOUR PHYSICIAN AND AGENCY IMMEDIATELY. A CHEST X-RAY MUST BE PERFORMED PRIOR TO WORKING AGAIN.

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Signed by Richard Williams
Signed On: March 15, 2023

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Document name: TB Questionnaire

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March 8, 2023 2:30 pm EDT

TB Questionnaire Uploaded by Assist Medical Staffing - staff@assistms.com IP 104.128.161.243

March 8, 2023 2:31 pm EDT

Document owner richard@assistms.com has handed over this document to staff@assistms.com 2023-03-08 14:31:25 - 104.128.161.76

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