Tb Risk Assessment Form - Stafford County Public Schools
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2STAFFORD COUNTY PUBLIC SCHOOLS HEALTH SERVICES
Screening Created by PD 16 School Health TEAM
TUBERCULOSIS RISK ASSESSMENT FOR ALL NEW STUDENTS - CONFIDENTIAL
NAME:
GRADE/SCHOOL:
PARENT/GUARDIAN:
DATE:
The United States Public Health Service and the Centers for Disease Control and Prevention (CDC) recommend that tuberculosis
(TB) testing be performed on all individuals who may be at increased risk of TB. Please complete the following form.
1.
Was the student born in a country outside of the United States?
____ No
____ Yes
If yes, what country? ________________________________________
2.
Has the student spent three or more consecutive months in a foreign country in the last five years?
____ No
____ Yes
If yes, what country? ________________________________________
3.
Has the student been exposed to or had contact with a person with active TB in the last year?
____ No
____ Yes
If yes, who? ______________________________________________
4.
Was the student homeless/incarcerated or did he/she live in a shelter during the last two years?
____ No
____ Yes
5.
Does the student have any of the following: persistent cough, coughed up blood, fever for more than one week,
unexplained weight loss or HIV infection?
_____ No
____ Yes
If yes, please explain: ________________________________________
6.
Is the student currently taking oral steroid medication (other than inhalers), cancer treating drugs or any other medication
that might weaken his/her immune system?
____ No
____ Yes
If yes, please explain: ________________________________________
7.
Has the student ever had a positive test for TB or been treated for active TB disease or latent TB infection?
____ No
____ Yes
If yes, please provide details: __________________________________
__________________________________________________________
__________________________________________________________
8.
Does the student have any of the following medical conditions?
a.
Diabetes
No
Yes
f. Gastrectomy
No
Yes
b.
Malnutrition
No
Yes
g. Silicosis
No
Yes
c.
Cancer
No
Yes
d.
Chronic renal failure
No
Yes
e.
Congenital or acquired
Immunodeficiency
No
Yes
INSTRUCTIONS FOR HEALTHCARE PROVIDER: Please complete the following when the risk assessment
contains one or more positive (yes) answers. Return to the school nurse.
Date of TB test: ______________
-Type of TB Test: TB skin test OR IGRA (interferon gamma release assay)
Test result: ______ mm induration (for TST)
OR
IGRA result:
Positive
Negative
Indeterminate
CXR ordered? No____ Yes____
-If yes, result: ___________________________________________________
Treatment provided? No____ Yes____
-If yes, what? ______________________________________________
Name of Health Care Provider (please print): _________________________________________________________
Address: ______________________________________________________________________________________
Telephone: ____________________________________________________________________________________
Signature: ______________________________________________________________________
Revised March 2015
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