HOWARD COUNTY GENERAL HOSPITAL, INC.
Occupational Health
Phone: 410-740-7838
Tuberculosis Screening Form
Fax: 410-740-7685
PRINT:
First Name_______________________________ Last Name______________________________ SSN/last 4 digits:___________
Home Address:___________________________________________ City:________________________State:__________ Zip:___________
Date of Birth:_________________ Sex: o F
o M
Contact phone #_______________________ Email:_______________________
Dept:____________________ Job Title:__________________ Manager Name:_________________________ / Phone #_______________
o Yes
o No
*Do you have contact with patients or work in patient care areas?
Please answer the following questions:
o TB Skin Test
o TB Blood Test
1. Your last TB screening was a:
Result: o UNSURE
o NEG
o POS / Size: _________mm induration
*When:_______________________
o YES
o NO
o UNSURE
2. Was a chest x-ray done after that TB test?
o YES
o NO
o UNSURE
3. Have you EVER had a positive TB test result?
o YES
o NO
o UNSURE
4. Did you ever take medication for TB?
*If "yes", Name of medication taken:________________________________________
*Number of months medication taken for:____________________________________
5. Country of Birth:____________________________
6. Have you had the BCG vaccine (a vaccine for TB)? o YES
o NO
o UNSURE
o
7. Do you have any of the following symptoms?
NONE
o Cough
o Fatigue
o Fever
o Night Sweats
o Decreased Appetite
o Chest Pain o Weight Loss
o
Bloody, yellow or green sputum
8. Check all that apply to you:
o Recent live vaccines: measles, MMR, varicella, flu mist intranasal vaccine, typhoid, etc. (Delay TST for 4 weeks)
o Do you scrub up to your elbows for any procedures (place TST in upper arm)
Employee Signature:______________________________________________
Date:_________________________
F
Employer: ____HCGH ____JHH ____JHHS ____Volunteer ____BSI ____Sodexho ____Student/Extern
O
*
____Contractor
____Other:___________________________________________________
R
Reason for Test: Pre-employment: ____1st ____2nd
____Annual
Exposure:
____Baseline
____Post
*
O
o 5mm
o 10m o 15mm
Tuberculin Skin Test (5TU Solution)
Note: Evaluate risk category:
F
F
________________________________________________________________________________________________________
I
Date Placed
Site
Administered by (PRINT)
Manufacturer
Lot#
Exp. Date
1
C
E
________________________________________________________________________________________________________
Date Read
mm induration
POS
NEG
Appearance
Signature
(None = 0, if reactive must see OHS)
U
S
o T-spot
IGRA:
E
2
_______________________________________________________________________________________________________
Date Collected
Collected by (PRINT NAME)
Result
Date Employee Notified
Staff Initial
O
N
Known Postive Symptom Review:
3
L
______________________________________________
o Sympton Review
o Documentation in ICMS
Y
Date CXR
Result
Staff Initial
Follow-up for Positive Result: Date CXR Req given:______________ Date CXR Completed:______________ Result:_____________
Copy to Employee________ Date LTBI Questionnaire Given:____________ Date Completed:____________ RN Initials:____________
Site Code:
LUA - Left Upper Arm
LFA - Left Forearm
RUA - Right Upper Arm
RFA - Right Forearm
TB SCREENING COMPLETED (DATE):______________________ OHS SIGNATURE:_______________________________________
1803-1 (03/11/11)