Pre-Employment Health Form For Employees/providers/volunteers In Child Care Centers Page 2
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TUBERCULOSIS (TB) SCREENING HISTORY
Please complete the following screening tool:
Have you come to Canada in the past 5 years from one or more of the following regions? Yes No
•
Asia (including Middle Eastern Countries)
•
Africa
•
Central and South America
•
Eastern Europe
Have you spent more than 3 consecutive months in one or more of the following regions in the last 5 years? Yes No
•
Asia (including Middle Eastern Countries)
•
Africa
•
Central and South America
•
Eastern Europe
Do you have any of the medical conditions listed below? Yes No
•
Kidney Problems
•
HIV/AIDS
•
Diabetes
•
Silicosis
•
Cancer
Do you take immune suppressing medications? Yes No
Have you been exposed to someone with tuberculosis in the past? Yes No
If you answered YES to any of the above questions TB Skin Testing is required.
Complete testing section below.
If you are unsure how to answer any of the above questions, please contact your family physician or call Region of
Waterloo Public Health at (519) 575-4400.
A one step (not two step) TB skin test is required for those child care providers
Result (in
Date of test
and employees who have answered YES to any of the above TB screening
mm)
questions.
The testing should be completed within six months prior to commencing employment and is strongly
recommended for volunteers who expect to work more than 150 hours/year (one half day per week).
______/____/____
Note: Employees working at multiple sites or changing employment in the child care sector within
Waterloo Region only require one TB skin test ever; therefore the 6 month requirement would apply
only to the first job.
Chest X-ray
______/____/____
If needed due to a positive skin test reaction as recommended by the health care practitioner at the
time of testing. A repeat chest x-ray is not required within six months of hire.
TB skin test may be obtained through your family physician (will charge a fee as advised by the College of
Physicians and Surgeons), a local walk-in clinic (fees vary) or can be arranged by calling Region of Waterloo
Public Health at 519-575-4400 (fee will also be charged).
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