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Record of Tuberculosis Screening (DHHS 3405)-2026
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- Click ‘Get Form’ to open the Record of Tuberculosis Screening (DHHS 3405) in the editor.
- Begin by filling in your Last Name, First Name, and Middle Initial in the designated fields at the top of the form.
- Enter your Patient Number and Date of Birth using the MM/DD/YYYY format. Ensure accuracy for proper identification.
- Select your Race and indicate if you are of Hispanic or Latino Origin by checking the appropriate boxes.
- Provide your Gender by selecting either Female or Male.
- In Section A, answer each health question regarding symptoms such as cough, fever, and fatigue by checking 'Yes' or 'No'.
- If all answers in Section A are 'No', sign and date where specified. If any two answers are 'Yes', do not complete this record.
- Section B must be completed by a licensed medical professional who will document test results and certify your tuberculosis status.
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Purpose: To be used for persons who: (1) have had a DocHub reaction to the tuberculin skin test;. (2) have had a negative chest X-ray;Read more
DHHS 3405 (Record of Tuberculosis Screening). Employees identified by agency risk assessment to be at risk for exposure shall be subsequently tested in