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TB Risk & Symptom Assessment

  • Please complete the form below as part of our annual TB documentation requirements.
  • If you have any questions please contact the office during normal business hours.

Have you:

ever had a positive reaction to a TB skin test

If yes give approximate date of positive reaction:

been in close contact with someone who has had infectious TB since your last TB test

lived in a country with a high TB rate for more than 1 month

received or planning to receive immunosuppressive treatment

ever had or been treated for exposure to TB

been exposed to a communicable pulmonary disease in the past 2 yrs

and have you experienced any of the following:

recent unexplained weight loss

pain in the chest

bad coughing lasting more than 3 weeks

coughing up blood

weakness or fatigue

loss of appetite

fever / chills / night sweats

 

Electronically sign your form:

By entering the following electronic signature & clicking "submit" you attest to the following statements:

I have answered the above questions truthfully and to the best of my ability. I understand that depending on my answers No Place Like Home may require additional screening and or medical evaluation to establish my TB risk as part of my continued employment.

If there are any changes in the information answered above I understand it is my duty to seek appropriate medical attention and to notify No Place Like Home administration.

 

First name: Last name:

Date of birth: / /

Last 4 digits of SSN:



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