Tuberculosis Risk Assessment Form
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1
2Gustavus Adolphus College
Tuberculosis (TB) Risk Assessment
TO BE COMPLETED BY HEALTH CARE PROVIDER
Return To: Gustavus Health Service, 800 West College Avenue, Saint Peter, MN 56082
Name: _________________________________________________________________ Date of Birth: _____________________
Part II: Clinical Assessment by Health Care Provider
Clinicians should review and verify the information provided by patient in part I. Persons answering YES to any of the questions on the TB
Screening form should be evaluated to determine if further testing is needed (either TST or IGRA). *If no testing is indicated, please document
reason (i.e.: travel exposure not significant) in #5 of this part II assessment.
History of positive TB skin test or IGRA blood test? (If yes, document below)
Yes
No
History of BCG vaccination? (If yes, consider IGRA if possible)
Yes
No
1
1.
TB Symptom Check
Does the student have signs or symptoms or 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 without sputum production
____Coughing up blood (hemoptysis)
____Chest pain
____Loss of appetite
____Unexplained weight loss
____Night sweats
____Fever
Proceed with additional evaluation to exclude active tuberculosis disease including tuberculin skin testing, chest x-ray, and sputum evaluation as
indicated.
2. Interferon Gamma Release Assay (IGRA) - QuantiFERON
QFT-GIT
T-Spot
Date Obtained: __________________ (specific method)
other ______________
Negative
Positive
Intermediate
Result:
Borderline (T-Spot only)
3. Tuberculin Skin Test (TST)
(TST result should be recorded as actual millimeters (mm) of induration, transverse diameter; if no indurations, write “0”.
The TST interpretation should be based on mm of indurations as well as risk factors.)**
Date TST given: ___________________ Date TST Read: __________________ Result ______________ mm of induration
**Interpretation:
Negative
Positive
** Interpretation guidelines
>5mm 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
*Immunosuppressed person: taking >15 mg/d of prednisone for > 1 month; taking TNF-a antagonist
*Persons with HIV/AIDs
>10 mm is positive:
*Persons born in a high prevalence country or who resided in one for a significant* amount of time
*History of illicit drug use
*Mycobacteriology laboratory personnel
*History of resident, worker or volunteer in high-risk congregate settings
*Persons with the following clinical conditions; silicosis, diabetes mellitus, chronic renal failure, leukemia’s and lymphomas, head, neck or lung cancer, low body
weight (>10% below ideal), gastrectomy or intestinal bypass, chronic malabsorption syndromes
>15 mm is positive:
*Persons with no known risk factors for TB disease
*The significance of the exposure should be discussed with a health care provider and evaluated
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CDC. Controlling Tuberculosis in the United States: Recommendations from the American Thoracic Society, CDC, and the Infectious Diseases Society of America. MMWR November 2005; 54 (No. RR-12): 4-5.
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