Positive Tb Screeners With Negative Chest-Xrays And Negative Quantiferon Tb-Gold Blood Tests

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Indiana State University College of Health and Human Services
Department of Baccalaureate Nursing Annual TB Assessment
Mandatory for known Positive TB Screeners with
negative chest-xrays and negative Quantiferon Tb-Gold blood tests
NAME:__________________________________________
DATE:___________________________
991________________________ NURSING PROGRAM/TRACK ________________________________
Complete the following questionnaire by initialing the correct response to the questions:
1. Were you vaccinated with BCG as a child?
Yes______
No______
2. Have you ever been diagnosed with TB and
received treatment?
Yes______
No______
3. Have you Knowingly been exposed to a person
diagnosed with TB within the past year?
Yes______
No______
4. Have you been evaluated for pulmonary symptoms
suggestive of TB in the last year?
Yes______
No______
5. Have you had a bad cough lasting longer than
three(3) weeks ?
Yes______
No______
6. Have you been coughing up blood, yellow, or green
sputum?
Yes______
No______
7. Have you experienced any excessive sweating
at night, or chills at night?
Yes______
No______
8. Have you experienced excessive fatigue,
weakness, or fever?
Yes______
No______
9. Have you had unexplained weight loss in
recent months?
Yes______
No______
10. Have you had any unexplained loss of
appetite in recent months?
Yes______
No______
If you answer yes to any of the questions please comment below and give dates of any events.
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
IT IS YOUR RESPONSIBILITY TO COMPLETE and SIGN THIS FORM ANNUALLY AND SUBMIT TO THE
STUDENT AFFAIRS OFFICE (RM 328). ADDITIONAL MEDICAL FOLLOW-UP MAY BE REQUIRED AFTER
DEPARTMENTAL REVIEW OF THIS FORM. FAILURE TO COMPLY MAY PREVENT OR DELAY CLINICAL
ATTENDANCE.
_______________________________________________________
________________________________________
Signature
Email

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