Full Name
Date of Birth
:_______________________________________________________
_____/_____/______
Last (Family Name or Surname)
First (Given Name)
month
day
year
Please Print Clearly
TOCCOA FALLS COLLEGE TUBERCULOSIS (TB) SCREENING FORM
Please answer the following questions:
Have you ever had close contact with persons known or suspected to have active
TB disease?
Yes
No
Were you born in one of the countries listed below that have a high incidence of active
TB disease? If yes, please CIRCLE the country, below.
Yes
No
Have you had frequent or prolonged visits* to one or more of the countries listed
below with a high prevalence of TB disease? (If yes, CIRCLE the countries, below)
Yes
No
Have you been a resident and/or employee of high-risk congregate settings (e.g.,
correctional facilities, long-term care facilities, and homeless shelters)?
Yes
No
Have you been a volunteer or health-care worker who served clients who are at
increased risk for active TB disease?
Yes
No
Have you ever been a member of any of the following groups that may have an
increased incidence of latent M. Tuberculosis infection or active TB disease –
medically underserved, low-income, or abusing drugs or alcohol?
Yes
No
* The significance of the travel exposure should be discussed with a health care provider and evaluated.
Cote d'Ivoire
Afghanistan
Kenya
Nigeria
Somalia
Djibouti
Algeria
Kiribati
Niue
South Africa
DPR of Congo
Angola
Kuwait
Pakistan
South Sudan
Dominican
Argentina
Kyrgyzstan
Palau
Sri Lanka
Republic
Armenia
Lao PDR
Panama
Sudan
Ecuador
Azerbaijan
Latvia
Papua New
Suriname
El Salvador
Bahrain
Lesotho
Guinea
Swaziland
Equatorial Guinea
Bangladesh
Liberia
Paraguay
Tajikistan
Eritrea
Belarus
Libya
Peru
Thailand
Estonia
Belize
Lithuania
Philippines
Timor-Leste
Ethiopia
Benin
Madagascar
Poland
Togo
Fiji
Bhutan
Malawi
Portugal
Trinidad &
Gabon
Bolivia
Malaysia
Qatar
Tobago
Gambia
Bosnia Botswana
Maldives
Rep. of Korea
Tunisia
Georgia
Brazil
Mali
Rep. of Moldova
Turkey
Ghana
Brunei
Marshall Islands
Romania
Turkmenistan
Guatemala
Darussalam
Mauritania
Russian
Tuvalu
Guinea
Bulgaria
Mauritius
Federation
Uganda
Guinea-Bissau
Burkina Faso
Mexico
Rwanda
Ukraine
Guyana
Burundi
Micronesia
St. Vincent &
United Rep of
Haiti
Cabo Verde
Mongolia
Grenadines
Tanzania
Herzegovina
Cambodia
Morocco
Sao Tome &
Uruguay
Honduras
Cameroon
Mozambique
Principe
Uzbekistan
India
Central African Rep.
Myanmar
Senegal
Vanuatu
Chad
Indonesia
Namibia
Serbia
Venezuela
China
Iran, Islamic
Nauru
Seychelles
Viet Nam
Columbia
Republic of
Nepal
Sierra Leone
Yemen
Comoros
Iraq
Nicaragua
Singapore
Zambia
Congo
Kazakhstan
Niger
Solomon Islands
Zimbabwe
If the answer is YES to any of the above questions, Toccoa Falls College requires that a health
care provider complete the Tuberculosis Risk Assessment Form (to be completed prior to the start
of classes).
If the answer to all of the above questions is NO, no further testing or action is
required.