Record of Tuberculosis Screening (DHHS 3405)-2026

1. Click ‘Get Form’ to open the Record of Tuberculosis Screening (DHHS 3405) in the editor.
2. Begin by filling in your Last Name, First Name, and Middle Initial in the designated fields at the top of the form.
3. Enter your Patient Number and Date of Birth using the MM/DD/YYYY format. Ensure accuracy for proper identification.
4. Select your Race and indicate if you are of Hispanic or Latino Origin by checking the appropriate boxes.
5. Provide your Gender by selecting either Female or Male.
6. In Section A, answer each health question regarding symptoms such as cough, fever, and fatigue by checking 'Yes' or 'No'.
7. If all answers in Section A are 'No', sign and date where specified. If any two answers are 'Yes', do not complete this record.
8. Section B must be completed by a licensed medical professional who will document test results and certify your tuberculosis status.

Start using our platform today to easily fill out your Record of Tuberculosis Screening for free!