Tuberculosis (Tb) Risk Assessment For Alaska Students

Tuberculosis   ( TB)   R isk   A ssessment   f or   A laska   S tudents

 

Student     N ame_______________________________________Birthdate___________Grade________                                            

 

Has   t he   s tudent   b een   i n   c ontact   w ith   a nyone   w ho   h as  

Yes  

No  

Notes  

active   T B   d isease   i n   t he   p ast   y ear?  

 

Is   t he   s tudent   f oreign-­‐born?*  

Yes  

No  

 

( Any   c ountry   o ther   t han   U .S.,  

 

Canada,   A ustralia,   N ew   Z ealand,   o r   W estern/Northern   E urope)

Has   t he   s tudent   t raveled   t o   c ountries   w ith   h igh   T B  

Yes  

No  

 

rates   f or   m ore   t han   a   m onth   c umulatively   d uring   t he  

past   y ear?  

( Any   c ountry   o ther   t han   U .S.,   C anada,   A ustralia,   N ew  

 

Zealand,   o r   W estern/Northern   E urope)

In   A laska,   T B   i s   m ost   c ommon   i n   t he   Y ukon-­‐

Yes  

No  

 

Kuskokwim   a nd   N orton   S ound   r egions.     D oes   t he  

student   l ive   i n   o ne   o f   t hese   r egions,   o r   h as   t he  

student   t raveled   t o   o ne   o f   t hese   r egions   f or   m ore  

than   a   m onth   c umulatively   d uring   t he   p ast   y ear?  

TB   R isk   A ssessment:     Alaska   l aw   r equires   a   T B   R isk   A ssessment   b e   o n   f ile   f or   a ll   s tudents   n ew   t o   t he   F airbanks  

North   S tar   B orough   S chool   D istrict.      

 

If  the  results  of  the  TB  Risk  Assessment  warrant,  a  TB  skin  test  will   b e   r equired   w ithin   9 0   d ays   o f  

enrollment   u nless   d ocumentation  of  one  of  the  following  is  provided  to  your  School  Nurse:    

 

1.     n egative   T B   s kin   t est   r esults   a dministered   w ithin   t he   p revious   6   m onths;    

2.     n egative   r esult   f rom   a n   a lternative   l aboratory-­‐approved   m ethod   a dministered   w ithin   t he   p receding   6   m onths  

for   a ssessing   t uberculosis   s tatus;    

3.     p ositive   r esult   a t   a ny   t ime   o n   t he   P PD   s kin   t est   o r   o ther   a lternative   l aboratory-­‐approved   m ethod   f or   a ssessing  

tuberculosis   s tatus      

See 7 AAC 27.213. Tuberculosis screening of school children and AS 14.30.045 for more information

 

My   s ignature   b elow   a ttests   t o   t he   a ccuracy   o f   t he   a bove   r esponses   a nd   g ives   t he   S chool   N urse   p ermission   t o  

administer   a   T B   s kin   t est   i f   w arranted.    

 

 

Parent/Guardian   n ame   ( print)      

   

 

 

 

Parent/Guardian   S ignature      

    D ate