TB Risk Questionnaire



    Please complete this questionnaire for active employees or contractual staff/physicians/volunteers. This form should be filled out completely and returned ASAP and no later than the end of the month it was issued. Follow up TB testing may be required for some.

    Please Check the box if you are currently experiencing any of the following symptoms or risk factors.



    RISK FACTORS With In The Last Year


    HIGH


    MEDIUM


    LOW


    NONE


    *Medical risks: Diabetes mellitus, smoker within past one year, leukemia, lymphoma, silicosis, cancer of head or neck, intestinal bypass/gastrectomy, chronic malabsorption, body mass index < 20

    +High TB prevalence country: Africa, Asia/Pacific, Eastern Europe incl. Russia, Latin America incl. Mexico.

    Interferon Gamma Release Assay is preferred over Tuberculin Skin Test for foreign-born persons.