Tuberculosis Risk Assessment printable pdf download

STUDENT HEALTH SERVICES

University of Massachusetts Lowell

TUBERCULOSIS RISK ASSESSMENT

Student Health Services

(Page 1 of 2 sided form)

71 Wilder Street, Suite 5

Lowell, Massachusetts 01854-3091

Tel: 978.934.4991 Fax: 978-934-3080

Name: _________________________________________________________________ Male _______ Female_______

Last

First

M.I.

Date: ___/___/_____

DOB: ___/___/_____

SID#: _____________________ Country of Birth: __________________

Home Address: ____________________________________________________________________________________

Local Address: ____________________________________________________________________________________

Phone Number: (home) ___________________________________(cell) ______________________________________

Please answer the following questions:

1. Have you ever been in close contact with anyone sick with tuberculosis?

Yes

2. Were you born in one of the countries listed below?

Yes

If yes, what country: ________________________ Date of entry to United States: ___________ ___

3. Have you lived or traveled for more than one month in one or more of the countries listed below?

Yes

If yes, what country/ies: __________________________ When: _____________________________

If the answer is YES to any of the above questions, the University of Massachusetts – Lowell requires you to have a

tuberculin skin test (TST) to check for latent tuberculosis infection (LTBI) to be completed within 6 months prior to the start

of classes. If you have had a positive TST in the past, you will not need another TST but you will need a chest X-ray.

Continue to Page 2 of this form.

If the answer is NO to all of the above questions, no further testing is required. Form is complete.

COUNTRIES WITH HIGH RATES OF TUBERCULOSIS

Afghanistan

Central African Republic

Guatemala

Malawi

Palau

Suriname

Algeria

Chad

Guinea

Malaysia

Panama

Syrian Arab Republic

Angola

China

Guinea-Bissau

Maldives

Papua New Guinea

Swaziland

Anguilla

Colombia

Guyana

Mali

Paraguay

Tajikistan

Argentina

Comoros

Haiti

Marshall Islands

Peru

Tanzania-UR

Armenia

Congo

Honduras

Mauritania

Philippines

Thailand

Azerbaijan

Congo DR

India

Mauritius

Poland

Timor-Leste

Bahamas

Cote d’Ivoire

Indonesia

Mexico

Portugal

Togo

Bahrain

Croatia

Iran

Micronesia

Qatar

Tokelau

Bangladesh

Djibouti

Iraq

Moldova-Rep

Romania

Tonga

Belarus

Dominican Republic

Japan

Mongolia

Russian Federation

Tunisia

Belize

Ecuador

Kazakhstan

Montenegro

Rwanda

Turkey

Benin

Egypt

Kenya

Morocco

St. Vincent & Grenadines

Turkmenistan

Bhutan

El Salvador

Kiribati

Mozambique

Sao Tome & Principe

Tuvalu

Bolivia

Equatorial New Guinea

Korea-DPR

Myanmar

Saudi Arabia

Uganda

Bosnia & Herzegovina

Eritrea

Korea-Rep

Namibia

Senegal

Ukraine

Botswana

Estonia

Kuwait

Nauru

Seychelles

Uruguay

Brazil

Ethiopia

Kyrgyzstan

Nepal

Sierra Leone

Uzbekistan

Brunei Darussalam

Fiji

Lao PDR

New Caledonia

Singapore

Vanuatu

Bulgaria

French Polynesia

Latvia

Nicaragua

Solomon Islands

Venezuela

Burkina Faso

Gabon

Lesotho

Niger

Somalia

Vietnam

Burundi

Gambia

Liberia

Nigeria

South Africa

Wallis & Futuna Islands

Cambodia

Georgia

Lithuania

Niue

Spain

West Bank & Gaza Strip

Cameroon

Ghana

Macedonia-TFYR

Northern Mariana Island

Sri Lanka

Yemen

Cape Verde

Guam

Madagascar

Pakistan

Sudan

Zambia

Zimbabwe

* World Health Organization Global Tuberculosis Control. WHO Report 2006.

Rev. 3/1/09

Tuberculosis Risk Assessment

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