Tuberculosis (Tb) Risk Assessment Form

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The University of Tennessee, Knoxville
Tuberculosis (TB) Risk Assessment Form
First Name: ______________________________
Last Name: _______________________________ Telephone: ______
Social Security #: ___________________________________
Date of Birth: _____________________________
To Health Care Provider:
This student's responses on our TB Screening Questionnaire confirm an increased risk for TB infection. The
following information is therefore required to complete their registration process for the University.
All indicated testing must be performed within the 6 months prior to the first day of the student's first
semester of classes.
1. Risk Factors (Review with patient.)
A prior positive TB test
��Yes
��No
Recent close contact with someone with infectious TB disease
��Yes
��No
Foreign-born from (or travel* to/in) a high-prevalence area (e.g., Africa, Asia, Eastern
��Yes
��No
Europe, or Central or South America)
Fibrotic changes on a prior chest x-ray suggesting inactive or past TB disease
��Yes
��No
HIV/AIDS
��Yes
��No
Organ transplant recipient
��Yes
��No
����Immunosuppressed��(equivalent��of��>��15��mg/day��of��prednisone��for��>1��month��or��TNF-α
��Yes
��No
antagonist)
History of illicit drug use
��Yes
��No
Resident, employee, or volunteer in a high-risk congregate setting (e.g., correctional
facilities, nursing homes, homeless shelters, hospitals, and other health care
��Yes
��No
facilities)
Medical condition associated with increased risk of progressing to TB disease if
infected [e.g., diabetes mellitus; silicosis; head, neck, or lung cancer; hematologic or
reticuloendothelial disease, such as Hodgkin’s disease or leukemia; end stage renal
��Yes
��No
disease; intestinal bypass or gastrectomy; chronic malabsorption syndrome; or low body
weight (i.e., 10% or more below ideal for the given population)]
* The significance of the travel exposure should be discussed with a health care provider and evaluated.
2. Does the student have signs or symptoms of active TB, e.g. fever, night sweats,
��Yes
��No
hemoptysis, prolonged cough, or weight loss?
If yes , proceed with testing as indicated, e.g. TSTor IGRA, chest x-ray, sputum AFB smear and cultures.
Ongoing treatment for TB will not prevent the student's enrollment.
If no , proceed to number 3.
3. Tuberculin Skin Test (TST) OR Interferon Gamma Release Assay (IGRA)
Do not use TST within four weeks of a live virus vaccine.
TST result should be recorded as actual millimeter of induration, transverse diameter; if no induration, write “0”.
The TST interpretation should be based on millimeter of induration as well as risk factors. See page 2.**
Date Given: ____ / ____ / ____
Result: ________ mm of induration
M
D
Y
Date Read: ____ / ____ / ____
**Interpretation: Negative / Positive
M
D
Y
_______________________________________________________________________________________________
Date Given: ____ / ____ / ____
Result: ________ mm of induration
M
D
Y
Date Read: ____ / ____ / ____
**Interpretation: Negative / Positive
M
D
Y
page 1 of 2
(eff. 3/23/12)

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