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Fcps tb screening form

Tb screening form 2025

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The document is a TB Screening Form required annually for employees enrolled in the UAB OH&S Employee Health Program who have positive TB skin tests. It includes sections for personal information, medical history related to tuberculosis, and symptoms experienced within the past year. Employees must answer questions truthfully and certify the accuracy of their responses, acknowledging that a 'Yes' answer may lead to further evaluation by UAB Employee Occupational Health.

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Click ‘Get Form’ to open the TB Screening Form in the editor.
Begin by entering your personal information. Fill in your name, Blazer ID, and date at the top of the form.
Proceed to answer the questions truthfully. For each question, either fill in the blank or circle 'Y' for Yes or 'N' for No as appropriate.
For questions regarding your medical history, such as previous tests and symptoms, provide detailed responses where required.
If you answered 'Yes' to any questions about potential TB exposure or symptoms, ensure you provide explanations in the designated area.
Finally, sign and date the form at the bottom. Ensure a witness also signs if required.

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What questions do they ask for TB screening?

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 the 4S complex for TB?

At ART centers, all PLHIV are screened for TB at every visit, using the 4-symptom (4S) complex which includes cough of any duration, fever, weight loss, and night sweats among adults. In children, the 4S complex includes current cough, fever, poor weight gain, and history of contact with a TB case.

How do I get proof of TB test?

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 is the screening test for TB?

Ask your health care provider for a written record of your positive TB test result. This will be helpful if you are asked to have another TB test in the future.

What are the 4 symptom screening for TB?

The World Health Organization (WHO) recommends that PLHIV, including pregnant women, should be routinely screened for symptoms of active TB at every health facility visit using a four‐symptom screen (cough, fever, night sweats, and weight loss (WHO 2011a).

printable tb test form

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What are the 4 TB screening questions?

TST Documentation Requirements Name and signature of person administering test. Date and time test administered. Location of test (e.g., right forearm, left forearm, alternate site) Tuberculin manufacturer, lot number and expiration date.