Required Immunization Form For Graduate Students Page 2
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2Patient Name:__________________________________________________________
DOB: ____________________________
TUBERCULOSIS (TB) SCREENING QUESTIONNAIRE
PART I: TUBERCULOSIS (TB) SCREENING QUESTIONNAIRE
(TO BE COMPLETED BY INCOMING STUDENTS)
Please answer the following questions:
q
q
Have you ever had close contact with persons known or suspected to have active TB disease?
YES
NO
q
q
Were you born in one of the countries or territories listed below that have a high incidence of
YES
NO
active TB disease? (If yes, please CIRCLE the country, below)
Afghanistan
China
Guam
Malaysia
Paraguay
Tajikistan
Algeria
China, Hong Kong SAR
Guatemala
Maldives
Peru
Thailand
Angola
China, Macao SAR
Guinea
Mali
Philippines
Timor-Leste
Anguilla
Colombia
Guinea-Bissau
Marshall Islands
Poland
Togo
Argentina
Comoros
Guyana
Mauritania
Portugal
Trinidad and Tobago
Armenia
Congo
Haiti
Mauritius
Qatar
Tunisia
Azerbaijan
Côte d’Ivoire
Honduras
Mexico
Republic of Korea
Turkmenistan
Bangladesh
Democratic People’s
India
Micronesia
Republic of Moldova
Tuvalu
Belarus
Republic of Korea
Indonesia
(Federated States of)
Romania
Uganda
Belize
Democratic Republic of
Iran
Mongolia
Russian Federation
Ukraine
Benin
the Congo
(Islamic Republic of)
Montenegro
Rwanda
United Republic of
Bhutan
Djibouti
Iraq
Morocco
Saint Vincent and the
Tanzania
Bolivia
Dominican Republic
Kazakhstan
Mozambique
Grenadines
Uruguay
(Plurinational State of)
Ecuador
Kenya
Myanmar
Sao Tome and Principe
Uzbekistan
Bosnia and Herzegovina
El Salvador
Kiribati
Namibia
Senegal
Vanuatu
Botswana
Equatorial Guinea
Kuwait
Nauru
Serbia
Venezuela (Bolivarian
Brazil
Eritrea
Kyrgyzstan
Nepal
Seychelles
Republic of)
Brunei Darussalam
Estonia
Lao People’s
Nicaragua
Sierra Leone
Vietnam
Bulgaria
Ethiopia
Democratic Republic
Niger
Singapore
Yemen
Burkina Faso
Fiji
Latvia
Nigeria
Solomon Islands
Zambia
Burundi
French Polynesia
Lesotho
Northern Mariana
Somalia South Africa
Zimbabwe
Cabo Verde
Gabon
Liberia
Islands
South Sudan
Cambodia
Gambia
Libya
Pakistan
Sri Lanka
Cameroon
Georgia
Lithuania
Palau
Sudan
Central African Republic
Ghana
Madagascar
Panama
Suriname
Chad
Greenland
Malawi
Papua New Guinea
Swaziland
Source: World Health Organization Global Health Observatory, Tuberculosis Incidence 2014. Countries with incidence rates of ≥ 20 cases per 100,000 population. For future updates, refer
to
q
q
Have you had frequent or prolonged visits* to one or more of the countries or territories listed
YES
NO
above with a high prevalence of TB disease? (If yes, CHECK the countries or territories, above)
q
q
Have you been a resident and/or employee of high-risk congregate settings (e.g., correctional
YES
NO
facilities, long-term care facilities, and homeless shelters)?
q
q
Have you been a volunteer or health care worker who served clients who are at increased risk
YES
NO
for active TB disease?
q
q
Have you ever been a member of any of the following groups that may have an increased
YES
NO
incidence of latent M. tuberculosis infection or active TB disease: medically underserved,
low-income, or abusing drugs or alcohol?
If the answer is YES to any of the above questions, Roger Williams University requires that you receive TB testing as soon as possible but
at least prior to the start of the subsequent semester).
If the answer to all of the above questions is NO, no further testing or further action is required.
* The significance of the travel exposure should be discussed with a health care provider and evaluated.
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