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Tuberculosis screening form 2025

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The document is an Annual TB Screening Form that collects personal information regarding an individual's history with tuberculosis, including previous infections, vaccinations, and current symptoms. It requires details about past positive tests and treatments, as well as a signature for compliance with health regulations.

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Click ‘Get Form’ to open the tuberculosis screening form in the editor.
Begin by entering your name and Social Security Number in the designated fields at the top of the form.
Indicate whether you have ever had tuberculosis by selecting 'Yes' or 'No'. If 'Yes', provide details including the date of your positive test and any treatment received in the space provided.
Next, answer whether you have received the BCG vaccine. If applicable, enter the year you received it.
Respond to whether you have had a positive TB skin test, including the date if applicable. If treated, list the treatment dates and type.
Review and check any current symptoms you may have from the list provided. Ensure to mark 'Yes' or 'No' for each symptom.
Finally, sign and date the form at the bottom before submitting it through our platform.

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How do you screen a TB patient?

Blood tests A sample of blood is sent to a lab. One lab test finds out whether certain immune system cells can recognize tuberculosis. A positive test shows that you have either a latent TB infection or active TB disease. Other tests of the blood sample can help determine if you have active disease.

What is the primary screening for TB?

The primary screening method for tuberculosis (TB) infection (active or latent) is the Mantoux tuberculin skin test with purified protein derivative (PPD). An in vitro blood test based on interferon-gamma release assay (IGRA) with antigens specific for Mycobacterium tuberculosis can also screen for latent TB infection.

What is tuberculosis test certificate?

Youll be given a chest x-ray to test for TB . If the result of the x-ray is not clear you may also be asked to give a sputum sample (phlegm coughed up from your lungs). If your test shows that you do not have TB , youll be given a certificate which is valid for 6 months from the date of your x-ray.

What is tuberculosis screening test?

TB blood tests (also called interferon-gamma release assays or IGRAs) use a blood sample to find out if you are infected with TB germs. The tests measure how your immune system reacts when a small amount of your blood is mixed with TB proteins.

What are the screening questions for TB?

Yes No Have you ever had a positive TB skin test or history of active tuberculosis infection? Yes No Has anyone living in your household ever had a history of active tuberculosis? Yes No Have you worked or volunteered in a nursing home, hospital, homeless shelter, prison or other health care facility?

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What are the TB screening questions?

Please answer the following questions: Have you ever had a positive TB skin test? Have you ever had close contact with anyone who was sick with TB? Have you ever been vaccinated with BCG? * The significance of the travel exposure should be discussed with a health care provider and evaluated.

What questions should I ask for TB exposure?

Tuberculosis Risk Assessment Have you had a cough lasting more than three weeks? Have you lived with or spent time with anyone who had or may have had TB? Have you lived in or visited any of the following areas for more than a month: Africa, Asia, Mexico, Central or South America, the Caribbean or Eastern Europe?

What is included in a TB screening?

A TB test checks to see if youve been infected with tuberculosis (TB). There are two types of TB tests: a skin test and a blood test. TB skin and blood tests can show if youve ever been exposed to the bacterium that causes TB, but they cant determine if you have a latent (dormant) or active TB infection.