Healthcare Worker Or Student Tb Assessment
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1
2
3URN:
Family name:
Given names:
TUBERCULOSIS CONTROL
Address:
Healthcare Worker / Student
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Phone no:
TB Assessment and Screening
Date of birth:
Sex:
M
F
…………..............................................................
Facility name:
To assist with assessing the need for TB screening, please complete all questions. TB screening is
open to all healthcare workers / students even if the screening criteria on page 3 are not met. Health
care workers, if you would like to be screened for TB, please notify your Staff Health Nurse who will
arrange testing. Students, please liaise with your University Administrator about their screening
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arrangements. Please bring this form with you when you are tested.
1. Were you born in Australia?
Yes
No
If no, in what country were you born?
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What year did you arrive in Australia?
2. Have you visited and/or lived in other countries for 3 months or more within the last 3
Yes
No
years?
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Please provide country/ies:
3. Have you ever been diagnosed with TB?
Yes
No
If Yes, what date did you complete treatment?
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/
Duration of treatment …… months
Name of health provider:
Where:
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Treatment prescribed:
4. Have you ever been in contact with a person with active TB disease?
Yes
No
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If yes, when/where?
5. Have you ever been screened for TB i.e. Chest x-ray, Tuberculin Skin Test (Mantoux)
Yes
No
and/or IGRAs (QuantiFERON Gold Assay)?
If yes, please provide date:
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/
Where:
Results:
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Date:
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/
Where:
Results:
6. Have you ever had a BCG vaccination?
Yes
No
If yes, date:
/
/
Clinic:
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7. Have you previously worked in any of the following settings?
7.1. Respiratory units, infectious disease units or other medical units caring for TB
Yes
No
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patients
7.2. Clinical procedures units designed for investigation and have a high risk of
Yes
No
transmitting suspected or unsuspected TB i.e. bronchoscopy, sputum induction,
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BCG bladder installations /immunotherapy
7.3. Microbiology and/other laboratories that handle specimens which may contain
Yes
No
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mycobacteria
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7.4. Mortuaries
Yes
No
8. Will you be working in any of the above areas of your current health care setting?
Yes
No
(*Students, please see Screening Criteria on next page)
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9. Do you have any of the following symptoms?
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9.1. Cough of >2 weeks
Yes
No
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9.2. Fevers
Yes
No
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9.3. Recent unexplained weight loss
Yes
No
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9.4. Haemoptysis (blood in sputum)
Yes
No
9.5. Night sweats
Yes
No
9.6. If yes to any, please describe:
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