TB Risk Questionnaire Employee: Department: Date: 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. Productive cough that has lasted 3 weeks or more.Unexplained fevers.Night Sweats.Overwhelming sense of fatigue.Loss of appetite/anorexiaUnexplained weight loss.Coughing up bloodI am NOT experiencing any of the symptoms listed above. If you checked any of the above symptoms, please explain your reasoning RISK FACTORS With In The Last Year HIGH Past History of chest x-ray with fibrotic changes an no history of TB disease treatment, or other findings suggestive of inactive or old TBHIV infectionCurrent or planned immune-suppression (Organ transplant, treatment with TNF-a antagonist, steroids other immunospuppressive medications)End-stage renal diseaseA previous history of close contact to someone with infections TBForeign-born person from a high TB prevalence country and has medical risk*Has stayed or worked in an urban homeless shelter and has medical risk*None of the above MEDIUM History of close contact to someone with infectious TB disease and NO medical risk*Contact with foreign-born person from high TB prevalent country and has NO medical risk*(Foreign exchange student or family member)Has stayed or worked in an urban homeless shelter and has NO medical risk*Traveled to or lived in high TB prevalence country for > 1 month and has medical risk*Traveled to or lived in high TB prevalence country for > 1 month and has NO medical risk*None of the above LOW Have been a healthcare worker or resident/employee of congregate setting (Correctional institution, long term-care facility, drug treatment facility)None of the above NONE No risk factors identified. *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. Employee Signature