Tuberculosis Screening Form
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1Student Name
G #
PART 4. TUBERCULOSIS SCREENING --
TO BE COMPLETED BY ALL STUDENTS
AND/OR HEALTHCARE PROVIDER
The following tuberculosis (TB) screening questions are required for all students. Refer to below list
of countries for Questions 1 and 2.
Select Yes or No
1. Were you born in a country where tuberculosis is endemic AND will arrive or have arrived in
Yes
No
the U.S. within the last five (5) years?
Date Arrived or Intended Date to Arrive in U.S.
Country of birth
2. Within the last five (5) years have you travelled for three (3) consecutive months or
Yes
No
more to countries where tuberculosis is endemic?
Date(s) of Travel last 5 years
Length of Stay
Country(ies) list
3. Have you had close contact with anyone who is or was sick with tuberculosis?
Yes
No
4. Have you ever tested positive for tuberculosis?
Yes
No
If yes, please provide documentation of history with chest x-ray report.
5. Do you have any medical conditions such as chronic renal failure, leukemia, or lymphoma, HIV
Yes
No
infection or any other immunosuppressive disorder?
6. Do you have any symptoms of active tuberculosis, such as: cough >3 weeks, night sweats,
Yes
No
fever, unexplained weight loss and/or fatigue?
7. Have you resided in, volunteered or worked in a high-risk congregate setting such as prisons,
Yes
No
nursing homes, hospitals or homeless shelters?
Initials of student or healthcare provider __________
If answers to ALL the above questions are NO, no TB testing or chest x-ray is required.
If the answer is YES to ANY of the above questions, George Mason University requires you to provide the
University with a tuberculosis test within the last 6 months.
List of Countries for Questions 1 and 2
(WHO reference 2016-2020)
Angola
Indonesia
Peru
Azerbaijan
Kazakhstan
Philippines
Bangladesh
Kenya
Russian Federation
Belarus
Korea, Democratic People's
Sierra Leone
Botswana
Republic
Somalia
Brazil
Kyrgyzstan
South Africa
Cambodia
Lesotho
Swaziland
Cameroon
Liberia
Tajikistan
Central African Republic
Malawi
Thailand
Chad
Moldova (Rep)
Uganda
China
Mozambique
Ukraine
Congo, Democratic Republic of
Myanmar
UR Tanzania
Ethiopia
Namibia
Uzbekistan
Ghana
Nigeria
Vietnam
Guinea-Bissau
Pakistan
Zambia
India
Papua New Guinea
Zimbabwe
3/2017A
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