Tuberculosis Screening Form - Department Of Education (Page 2 of 2) in pdf

Page 2: Tuberculosis Screening Form (cont’d)

Name: ___________________________________

Six months prior to the date shown at the top of the other side to be considered valid). If you are pregnant: do item

7 if you are less than 20 weeks pregnant (in this case Item 7 may be completed only by a physician); otherwise, do

this item, then Item 5 (tell the clinic you need an abdominally shielded X-ray because of your pregnancy).

Are X-ray results suggestive of TB?

[ ] Yes [ ] No

Date the X-ray was first administered:

_______________________

Is patient currently on INH preventive therapy?

[ ] Yes [ ] No

If not, please state reason:

[ ] Patient refuses INH therapy offered

[ ] Patient over 35 years of age with no risk factor

[ ] Patient referred to DPSS for possible INH therapy

[ ] Patient referred to DPHSS for possible active TB

Other ________________________________________________________________

_________________________________

__________________________________

Name of physician/PA/NP (print)

Signature

5. a) If the answer to Item 4.1 is “no”; disregard the following items.

b) If the answer to Item 4.1 is “yes”; do Item 9.

6. a) If the last time you had a chest X-ray was during or before 1995: do Item 4.

b) If you had a chest X-ray after 1995 and had submitted its radiology report with Item 4 properly completed to

GPSS for a previous TB screening: do Item 7. Otherwise, do Item 4.

7. Have the following item completed by only a physician, physician’s assistant, or nurse practitioner. Then do Item

8. (This item must have been completed no sooner than one year prior to the date shown at the top of the other

side to be valid).

Does the person named on Side 1 have any of the following?

A) Chromic cough: (2 weeks duration or longer)

[ ] Yes [ ] No

B) Chronic cough with sputum

[ ] Yes [ ] No

C) Coughing blood

[ ] Yes [ ] No

D) Persistent night sweats

[ ] Yes [ ] No

E) Involuntary weight loss

[ ] Yes [ ] No

F) Unexplained fevers

[ ] Yes [ ] No

_________________________________

_____________________________

_____________

Name of physician/PA/NP (print)

Signature

Date

8. a) If all of the symptoms A-F in Item 7 were answered “no”: disregard the remaining items.

b) If any of the symptoms A-F were answered “yes” in Item 7: do Item 4. (However, in this case the X-ray required

by Item 4 will be considered valid only if it has been conducted no more than one month prior to, or anytime after,

when Item 7 has been signed).

9. Have the Tb Control Section of the Department of Public Health & Social Services in Mangilao complete the

following; clearances from anywhere else will not be accepted (Call 735-7145/7157 for an appointment. When

doing so, ask what documents you should bring to get cleared.). You may return to work or resume you job

application process in the date indicated on the left below.

May start/return to work on: __________________________________ DPHSS Stamp:_____________________

DPHSS staff signature:______________________________________ Date: _____________________________

Tuberculosis Screening Form - Department Of Education Page 2

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