Tuberculosis (TB) Risk Assessment Questionnaire - colorado 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your Last Name, First Name, and contact details including Address, City, State, Zip, Phone, Email Address, and Date of Birth. Ensure all information is accurate for effective communication.
3. Proceed to the first question regarding your residency in specific regions. Select 'Yes' or 'No' and if applicable, list the countries you have lived in.
4. For the second question about chronic conditions affecting your immune system, check 'Yes' or 'No'. If 'Yes', mark all relevant conditions from the provided list.
5. Answer whether you have worked or volunteered in certain facilities by selecting 'Yes' or 'No', and check any applicable options.
6. Indicate any current symptoms by checking all that apply. This section is crucial for assessing potential TB risk.
7. Respond to questions about past contact with active tuberculosis cases and injection drug use by selecting the appropriate options.
8. If you have had a tuberculin skin test before, provide details including where it was given and attach results if available.
9. Finally, review your entries for accuracy. Sign and date the form to confirm that all information is true and complete.

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