Proof Of Immunization Compliance Form (Page 2 of 2) in pdf

TUBERCULOSIS QUESTIONNAIRE

ID Number: SO - _ _ _ - _ _ _ _

Name: ___________________________________

Date of Birth ______________

SECTION ONE: Please answer the following questions:

Afghanistan

Burkina Faso

Ecuador

Indonesia

Maldives

Niue

Sao Tome and Principe

Trinidad and Tobago

Algeria

Burundi

El Salvador

Iran

Mali

Pakistan

Senegal

Tunisia

Angola

Cabo Verde

Equatorial Guinea

Iraq

Marshall Islands

Palau

Serbia

Turkey

Argentina

Cambodia

Eritrea

Kazakhstan

Mauritania

Panama

Seychelles

Turkmenistan

Armenia

Cameroon

Estonia

Kenya

Mauritius

Papua New Guinea

Singapore

Tuvalu

Azerbaijan

Central African

Ethiopia

Kiribati

Mexico

Paraguay

Sierra Leone

Uganda

Bahrain

Republic

Fiji

Kuwait

Micronesia (Federated

Peru

Solomon Islands

Ukraine

Bangladesh

Chad

Gabon

Kyrgyzstan

States of)

Philippines

Somalia

United Rep. of

Lao People’s Dem.

Belarus

China

Gambia

Mongolia

Poland

South Africa

Tanzania

Belize

Colombia

Georgia

Republic

Morocco

Portugal

South Sudan

Uruguay

Benin

Comoros

Ghana

Latvia

Mozambique

Qatar

Sri Lanka

Uzbekistan

Bhutan

Congo

Guatemala

Lesotho

Myanmar

Republic of Korea

Sudan

Vanuatu

Cote d’Ivoire

Bolivia

Guinea

Liberia

Namibia

Republic of Moldova

Suriname

Venezuela (Bolivarian

Democratic People’s

Bosnia and

Guinea-Bissau

Libya

Nauru

Romania

Swaziland

Republic of)

Herzegovina

Rep. of Korea

Guyana

Lithuania

Nepal

Russian Federation

Tajikistan

Viet Nam

Botswana

Dem. Republic of the

Haiti

Madagascar

Nicaragua

Rwanda

Thailand

Yemen

Brazil

Congo

Honduras

Malawi

Niger

Saint Vincent and the

Timor-Leste

Zambia

Brunei Darussalam

Djibouti

India

Malaysia

Nigeria

Grenadine Islands

Togo

Zimbabwe

Bulgaria

Dominican Republic

Were you born in, have you ever lived in, or recently traveled to (within the past 5 years) any of the

Yes

countries listed above that have a high incidence of active TB disease?

(If yes, please CIRCLE the country)

Do you have a personal history of cancer, leukemia, kidney disease, diabetes, alcoholism, or intravenous

Yes

drug use?

(Family history does not apply)

Have you been a resident, employee, or volunteer in a prison, homeless shelter, hospital, nursing home,

Yes

or other long-term treatment facility?

Do you have AIDS/HIV or take immunosuppressive medication such as prednisone?

Yes

Have you ever had close contact with persons known or suspected to have active TB disease?

Yes

If the answer to all of the above questions is NO, no TB testing or further action is required.

If the answer is YES to any of the above questions, SUBR requires that you receive TB testing. The PPD skin test must be done within

the 12 months prior to beginning your classes. You can obtain the PPD skin test from your local health care provider.

(See Section two below)

SECTION TWO: Test Results

Step 1: Tuberculin Skin Test – Positive if ≥ 10mm for questions 1, 2, or 3 or ≥ 5mm for questions 4 or 5.

Date Given: _________

Date Read: _________

Result: _____ mm of Induration

Interpretation: Positive____ Negative____

Step 2: A QFT or T-SPOT is required if PPD is positive. A Chest X-Ray will not be accepted in its place. (Please provide a copy of results.)

Date Obtained: _________ Circle Method Given: QFT T-Spot

Result: Positive____ Negative____

Step 3: Students with a positive QFT or T-Spot should receive a Chest X-Ray.

Date of X-ray: _________ Result: Normal_________ Abnormal_________

Step 4: Students with a positive QFT or T-Spot with no signs of active disease on chest x-ray are recommended to be treated for Latent TB

with appropriate medication.

Name of Medications for treatment: ________________ Date Initiated & Duration of treatment: _________ (Please provide copy of

completion of treatment.)

_________ Student has been treated or agrees to receive treatment.

_________ Student declines treatment at this time and agrees to come in to the Student Health Center to sign the “Refusal of Treatment for Latent

TB”. Student also agrees to routine checkups to monitor progression of Latent TB.

Health Care Provider’s Name, Address, Phone #: ___________________________________________________________________

Health Care Provider’s Signature: _______________________________________________________________________________

**REMEMBER! You will not be eligible to pay University fees or move into the dormitory until all immunization records are in compliance or the

exemption is signed.

Please fax or mail the completed form to the SU Baranco-Hill Health Center. It can be accessed on the Student Health Center

homepage,

The completed form can also be submitted in person, by mail, and by fax:

SU Student Health Services

Fax: (225) 771-6225

Baranco-Hill Health Center

Tel: (225) 771-4770

P.O. Box 10174

Revised 09/2015

Helen Barron Drive

Baton Rouge, LA 70813

Page 2 of 2

Proof Of Immunization Compliance Form Page 2

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