Tuberculosis (Tb) Screening Form Page 2
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1
2Full Name
Date of Birth
:_______________________________________________________
_____/_____/______
Last (Family Name or Surname)
First (Given Name)
month
day
year
TOCCOA FALLS COLLEGE TUBERCULOSIS (TB) RISK ASSESSMENT FORM
(to be completed by Health Care Provider)
(Required only if yes to any of the questions asked regarding Tuberculosis Screening)
1. Does the student have signs or symptoms of active tuberculosis disease?
Yes _____ No _____
If No, proceed to 2 or 3.
If Yes, check below:
Cough (especially if lasting for 3 weeks or longer) with or
Unexplained weight loss
without sputum production.
Night sweats
Coughing up blood (hemoptysis)
Fever
Chest pain
Loss of appetite
Proceed with additional evaluation to exclude active tuberculosis disease including tuberculin skin testing, chest x-ray, and sputum evaluation as
indicated.
2. Tuberculin Skin Test (TST) (TST result should be recorded as actual millimeters (mm) of induration, transverse diameter; if no
induration, write “0”.
The TST interpretation should be based on mm of induration as well as risk factors.)**
Date Given: _____/_____/_____ Date Read: _____/_____/_____
month
day
year
month
day
year
Result: ________ mm of induration **Interpretation: positive_____ negative_____
Date Given: _____/_____/_____ Date Read: _____/_____/_____
month
day
year
month
day
year
Result: ________ mm of induration **Interpretation: positive_____ negative_____
**Interpretation guidelines
>5 mm is positive:
Recent close contacts of an individual with infectious TB
Persons with fibrotic changes on a prior chest x-ray consistent with past TB disease
Organ transplant recipients and other immunosuppressed persons: taking > 15 mg/d of prednisone for > 1month
HIV-infected persons
>10 mm is positive:
Recent arrivals to the U.S. (<5 years) from high prevalence country or who resided in one for a significant amount of time
Injection drug users
Mycobacteriology laboratory personnel
Residents, employees or volunteers in high-risk congregate settings
Persons with the following clinical conditions: silicosis, diabetes mellitus, chronic renal failure, certain types of cancer
(leukemias and lymphomas, cancers of the head, neck or lung), gastrectomy or jejunoileal bypass, and weight loss of at least 10% below
ideal weight
>15 mm is positive:
Persons with no known risk factors for TB, except for certain testing programs required by law or regulation
3. Interferon Gamma Release Assay (IGRA)
Date Obtained: _____/_____/_____ (specify method) QFT-G QFT-GIT other_____
month
day
year
Result: negative_____ positive_____ intermediate__________ borderline_____ (T-Spot only)
Date Obtained: _____/_____/_____ (specify method) QFT-G QFT-GIT other_____
month
day
year
Result: negative_____ positive_____ intermediate_____ borderline_____ (T-Spot only)
4. Chest x-ray: (Required if TST or IGRA is positive)
Date of chest x-ray: _____/_____/_____ Result: normal_____ abnormal_____
month
day
year
If positive, please provide the student a chest x-ray and a treatment plan to be given to the Toccoa Falls College Health Services
Office and Stephens County Health Department.
HEALTH CARE PROVIDER
Name ___________________________________________________
Date_______________
Please Print
Signature __________________________________________________________ Phone (______) _________________________
Address ____________________________________________________________________________________________________
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