Tuberculosis (Tb) Risk Assessment Form Page 2
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2Interferon Gamma Release Assay (IGRA)
Date Obtained: ____ /____ /____
(specify method)
QFT-G
QFT-GIT
T-Spot
other_____
M
D
Y
Result: Negative / Positive / Intermediate / Indeterminant
_________________________________________________________________________________________________
Date Obtained: ____ /____ /____
(specify method)
QFT-G
QFT-GIT
T-Spot
other_____
M
D
Y
Result: Negative / Positive / Intermediate / Indeterminant
4. Chest x-ray required within 6 months prior to start of classes for recent or prior positive TST or IGRA
Date Obtained: ____ /____ /____
Result: Normal / Abnormal
M
D
Y
5. Provide or attach information regarding past or present treatment for latent or active TB infection:
6. Health Care Provider Contact Information sign only when testing completed
Provider Name:
Address:
Provider Signature
City
State
Zip Code
Country
Phone Number: ______________________________________ Fax Number: ______________________________
Date
** TST Interpretation Guidelines
>5 mm is positive in:
•��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��persons:��taking��>��15��mg/d��of��prednisone��for��>��1��month;��taking��a��TNF-α��antagonist
•��Persons��with��HIV/AIDS
>10 mm is positive in:
•��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:��silicosis;��diabetes��mellitus;��chronic��renal��failure;��leukemias��and��lymphomas;��gastrectomy��or����
intestinal bypass; head, neck, or lung cancer; low body weight (>10% below ideal); and/or chronic malabsorption syndromes
>15 mm is positive in:
•��Persons��with��no��known��risk��factors��for��TB��disease
*The significance of the travel exposure should be discussed with a health care provider and evaluated.
Healthcare Provider: Please return this completed two page form to the address listed below. It must be received in
our office by 8/31 for Fall Enrollees or 1/31 for Spring Enrollees or a "Hold" will be placed on their account.
Immunization Coordinator
University of Tennessee, Student Health Center
1800 Volunteer Blvd.
Knoxville, TN 37996-3102
page 2 of 2
(eff. 3/28/12)
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