Tuberculosis (Tb) Screening Questionnaire - Missouri

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TUBERCULOSIS (TB) SCREENING QUESTIONNAIRE
Name:
Last Name (Please print)
First Name & MI (Please print)
G Number
Phone Number (cell or home)
Upon matriculation at Missouri Western State University, all students will complete the TB screening questionnaire in
compliance with Missouri State Law. Upon hiring at Missouri Western State University, all faculty and staff will complete
the TB screening questionnaire to aid in prevention and control of Tuberculosis. If testing is required, the process could
take up to two weeks to complete. DO NOT WAIT UNTIL THE LAST MOMENT.
Tuberculosis, also known as TB, is a bacterial infection that attacks the lungs and, sometimes, other parts of the body. It
is spread when someone infected with the disease coughs or sneezes and the bacteria is inhaled by someone nearby.
For additional information on TB:
PLEASE CIRCLE YES OR NO TO THE FOLLOWING QUESTIONS:
1. Have you ever had a tuberculosis (TB) test that was positive, been diagnosed with or treated
for TB disease?
YES
NO
2. Have you ever been a health care worker, volunteer, or employee of a nursing home, prison
or other residential institution?
YES
NO
3. Have you ever been in close contact with someone known to have active tuberculosis (TB)
YES
NO
4. Were you born in a country listed on the second page of this form?
Please list country of birth:
YES
NO
5. Have you ever spent more than 2 months at one time in a country on the list?
YES
NO
Please list the country:
If you answered YES to any of the above questions, you are required to provide documentation of further testing and
evaluation by a certified U.S. Healthcare Provider. Students may contact the Esry Student Health Center for follow
up.
1. You will be required to undergo a TB blood test instead of a TB skin test, if you were born in a country on the list
or have received the BCG vaccination, due to the risk of a possible false positive.
2. If you have had a past positive TB test, you will need to present documentation of a chest x-ray within the last
year or obtain one through a U.S. certified healthcare provider and have results submitted to the Esry Student
Health Center.
3. If you have received prior treatment for active TB disease, you will need to provide proper documentation of such
treatment to the Esry Student Health Center.
All student tests can be obtained at the Esry Student Health Center (for students), or by a U.S. certified health care
provider. All medical expenses will be the individual’s financial responsibility.
To the best of my knowledge, the information provided above is true and complete. I acknowledge that non-compliance
will result in students not being eligible to enroll for a subsequent semester; faculty / staff members may not work on
campus until screening is complete, per Missouri Western State University policy and Missouri law.
Signature
_Date_
If a student is under the age of eighteen (18), signature of a parent or legal guardian:
Parent or legal guardian’s signature
_Date_
Return this form to Esry Student Health Center, Missouri Western State University, 4525 Downs Drive, St. Joseph, MO 64507 or to the Human
Resources Department if you are new faculty/staff. Fax: (816) 271-4498. Email: health@missouriwestern.edu
Revised 11/1/16

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