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?

Have you ever been treated for active TB disease?

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)

2. Night sweats

3. Fever lasting several weeks

4. Frequent coughing in the absence of a cold or flu

5. Production of sputum

6. Coughing blood-streaked sputum

7. Unusual tiredness or weakness lasting weeks

8. Shortness of breath

9. Pain in chest when taking a breath

10. Have you been recently diagnosed with diabetes, silicosis, HIV disease, renal disease or liver disease?

11. Have you been recently exposed to a family member or others with active TB?

If you checked YES to any of the above symptom questions, is a physician currently treating you?

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


Signature Certificate
Document name: TB Questionnaire
lock iconUnique Document ID: bf1079255ca60e929d2132c5783094e7782c0c1c
Timestamp Audit
March 8, 2023 2:30 pm EDTTB 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