Adult Tuberculosis (Tb) Risk Assessment Questionnaire Form
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1
2Adult Tuberculosis (TB) Risk Assessment Questionnaire
1
(To satisfy California Education Code Section 49406 and Health and Safety Code Sections 121525‐121555)
To be administered by a licensed health care provider (physician, physician assistant, nurse practitioner, registered nurse)
Name: ___________________________________________________
Date of Risk Assessment: ______________________________
Date of Birth: _____________________________________________
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History of positive TB test or TB disease Yes
No
If yes, a symptom review and chest x‐ray (if none performed in previous 6 months) should be performed at initial hire.*
If no, continue with questions below.
If there is a “Yes” response to any of the questions 1‐5 below, then a tuberculin skin test (TST) or Interferon Gamma Release Assay (IGRA) should
be performed. A positive test should be followed by a chest x‐ray, and if normal, treatment for TB infection considered.
Risk Factors
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1. One or more signs and symptoms of TB
Yes
No
(prolonged cough, coughing up blood, fever, night sweats, weight loss, excessive fatigue)
2
Note: A chest x‐ray and/or sputum examination may be necessary to rule out infectious TB.
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2. Close contact with someone with infectious TB disease Yes
No
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3. Birth in high TB‐prevalence country** Yes
No
(**Any country other than the United States, Canada, Australia, New Zealand, or a country in Western or Northern Europe.)
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4. Travel to high TB‐prevalence country** for more than 1 month Yes
No
(**Any country other than the United States, Canada, Australia, New Zealand, or a country in Western or Northern Europe.)
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5. Current or former residence or work in a correctional facility, long‐term care facility, hospital, or homeless shelter Yes
No
*Once a person has a documented positive test for TB infection that has been followed by an x‐ray that was deemed free of infectious TB,
the TB risk assessment is no longer required.
1
Adapted from a form developed by Minnesota Department of Health TB Prevention and Control Program and Centers for Disease Control and Prevention.
2
Centers for Disease Control and Prevention (CDC). Latent Tuberculosis Infection: A Guide for Primary Health Care Providers. 2013.
( )
TCB‐01 (12/14) Effective January 1, 2015
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