Form Lic 701 - Physician'S Report - Child Care Centers Page 2

RISK FACTORS FOR TB IN CHILDREN:

Have a family member or contacts with a history of confirmed or suspected TB.

Are in foreign-born families and from high-prevalence countries (Asia, Africa, Central and South America).

Live in out-of-home placements.

Have, or are suspected to have, HIV infection.

Live with an adult with HIV seropositivity.

Live with an adult who has been incarcerated in the last five years.

Live among, or are frequently exposed to, individuals who are homeless, migrant farm workers, users of street drugs, or residents in

nursing homes.

Have abnormalities on chest X-ray suggestive of TB.

Have clinical evidence of TB.

Consult with your local health department’s TB control program on any aspects of TB prevention and treatment.

LIC 701 (8/08) (Confidential)

PAGE 2 of 2

0 votes

Parent category: Business