Adult Tuberculosis (Tb) Risk Assessment Questionnaire Form Page 2
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2ADULT TUBERCULOSIS (TB) RISK ASSESSMENT QUESTIONNAIRE
(To satisfy California Education Code Section 49406 and Health and Safety Code Sections 121525‐121555)
CERTIFICATE OF COMPLETION
To be signed by the licensed health care provider completing the risk assessment and/or examination
Name: ___________________________________________________
Date: ______________________________________
Date of Birth: _____________________________________________
The above named patient has submitted to a tuberculosis risk assessment. The patient does not
have risk factors, or if tuberculosis risk factors were identified, the patient has been examined and
determined to be free of infectious tuberculosis.
____________________________________________________________________________________________________________________
Health Care Provider Signature
____________________________________________________________________________________________________________________
Please Print Health Care Provider Name
Title
____________________________________________________________________________________________________________________
Office Address: Street
City
State
Zip Code
____________________________________________________________________________________________________________________
Telephone
Fax
TCB‐01 (12/14) Effective January 1, 2015
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