Adult Tb Risk Assessment Page 3
Download a blank fillable Adult Tb Risk Assessment in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Adult Tb Risk Assessment with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3Adult TB Risk Assessment and Screening Form
Instructions to Medical Providers
The purpose of the TB risk assessment and screening form is to identify persons with increased risk for TB
who may require further testing and evaluation. Persons born in countries where TB is common are at
increased risk for TB (especially, but not limited to those who arrived in the last 5 years).
The TB Self-Assessment of TB Risk section can be completed by the patient/client/guardian alone or with
provider’s assistance. The provider should review the information and discuss TB risks, symptoms, previous
TB testing and treatment with the patient/client.
If the person with TB risk describes or exhibits symptoms suggestive of possible active TB:
Isolate the patient/client immediately (if possible) and have the patient/client wear a mask.
•
Refer the patient/client for prompt clinical evaluation including a chest x-ray. Ensure that the
•
patient/client wears a mask during transport to the provider.
Consult the Massachusetts Department of Public Health/Bureau of Infectious Disease/ Division of
•
Global Populations and Infectious Disease Prevention at 617-983-6970.
If the person has a history of TB or TB risk, but has no symptoms suggestive of TB:
Educate the patient/client about signs and symptoms of TB and should such symptoms develop,
•
instruct them to seek medical follow-up.
Consider testing the patient/client for TB infection or refer to primary care provider.
•
Consult the Massachusetts Department of Public Health/Bureau of Infectious Disease, Division of
•
Global Populations and Infectious Disease Prevention at 617-983-6970, if needed.
Resources
Information about TB evaluation, testing and treatment can be found at and
Guideline on the use of Interferon-Gamma Release Assay can be found at
Cases of suspect active or confirmed cases of active TB and TB infection are reportable to the
Massachusetts Department of Public Health per Chapter 105, Code of Massachusetts Regulations
(CMR), Section 300.000: Reportable Diseases, Surveillance, and Isolation & Quarantine Requirements)
diseases-and-surveillance-information.html
DPH-supported TB clinics
Massachusetts Department of Public Health / Bureau of Infectious Disease /
3
Division of Global Populations and Infectious Disease Prevention
November 2013
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical